Nutrition management of enteral feeding - guidelines and procedures ect2353

CNSG Guidelines and Procedures for Management of Enteral Feeding Page 1 of 172
Created by Maggie Allen. October 2010. Updated July 2015.
.
Guideline Title: Clinical Nutrition Steering Group (CNSG)
Guidelines and Procedures for Management of Enteral Feeding
Executive
Summary:
To optimise the care of adult in-patients receiving nutrition via an enteral
feeding tube under the care of East Cheshire NHS Trust.
Supersedes: Version 1.2
Description of
Amendment(s):
Guidelines reviewed and updated
This guideline will impact on:
All staff caring for adult inpatients under the care of East Cheshire NHS Trust.
Financial Implications: Improvements in nutritional care should reduce costs and risks associated
with sub-optimal patient nutrition.
Guideline Area: Nutrition Document Reference: CNSG guidelines
Version Number: 1.3 Effective Date: August 2012
Issued By: Departments of Dietetics
and Gastroenterology
Review Date: June 2017
Author: Maggie Allen
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Committees / Group
Clinical Nutrition Steering Group
Date
August 2011
Consultation: Departments of Dietetics and
Gastroenterology
Infection prevention and control
June 2015
Approved by: Clinical Nutrition Steering Group July 2015
AMENDMENTS RECORD
August 2011 - Version 1.1 CNSG007 CNSG 008 and CNSG 012 guidelines updated for
NPSA/2011/PSA002 alert compliance
August 2012 -Version 1.2 CNSG007 CNSG 008 and CNSG 012 guidelines updated for
NPSA/2012/RRR001 alert compliance
June 2015 – Version 1.3 Guidelines reviewed and updated

CNSG Guidelines and Procedures for Management of Enteral Feeding Page 2 of 172
.
The following guidelines are to be used in association with CNSG 006 East Cheshire NHS
Trust Enteral Feeding Policy for Adults
MAIN INDEX
SECTION CONTENTS PAGE
CNSG007 GUIDELINES FOR INSERTION AND MANAGEMENT OF
NASOGASTRIC TUBES
3-26
CNSG 008 GUIDELINES FOR INSERTION AND MANAGEMENT OF NASAL
BRIDLES
27-37
CNSG 009 GUIDELINES FOR INSERTION AND MANAGEMENT OF
GASTROSTOMY TUBES
38-70
CNSG 010 PROTOCOL FOR FIRST ASSISTANT ROLE IN PEG INSERTION 71-79
CNSG 011 GUIDELINES FOR SUSPECTED PERITONEAL LEAK POST PEG
INSERTION
80-81
CNSG 012 GUIDELINES FOR MANAGEMENT OF A JEJUNAL TUBE 82-98
CNSG 013 GUIDELINES FOR ADMINISTRATION OF FEED 99-111
CNSG 014 GUIDELINES FOR ENTERAL FEEDING COMPLICATIONS AND
MANAGEMENT
112-130
CNSG 015 MICROBIOLOGICAL GUIDELINES FOR ENTERAL FEEDING 131-139
CNSG 016 GUIDELINES FOR ADMINISTRATION OF MEDICATION VIA
ENTERAL TUBES
140-153
CNSG 017 GUIDELINES FOR ASSESSMENT AND MONITORING OF
PATIENTS RECEIVING ENTERAL FEEDING
Available
on Trust
Intranet
CNSG 018 GUIDELINES FOR ENTERALLY FED PATIENTS ADMITTED TO
HOSPITAL
154-156
PATIENT INFORMATION AND FORMS FOR PRINTING
CARE PATHWAY FOR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY
(PEG) TUBES
158-165
ADVICE POST PEG REMOVAL 167
PRE-DISCHARGE TRAINING CHECKLIST- GASTROSTOMY FEEDING 167-168
NASOGASTRIC (NG) TUBE INSERTION AND MONITORING FORM 169-171

East Cheshire NHS Trust CNSG 007 Guidelines for Insertion and Management of Nasogastric Tubes Page 3 of 172
Created by Maggie Allen, October 2010. Updated March 2015.
Guideline Title: Guidelines for Insertion and Management of Nasogastric Tubes
Executive
Summary:
To optimise the care of adult in-patients receiving nutrition via a
nasogastric tube under the care of East Cheshire NHS Trust.
Description of
Amendment(s):
Guidelines reviewed - no major changes
Guideline Area: Nutrition Document Reference: CNSG 007
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Committees / Group
Date
August 2011
Gastroenterology
October 2010- August
2011.
June 2015
AMENDMENT RECORDS
August 2011 - Version 1.1 Guidelines updated for NPSA/2011/PSA002 alert compliance.
May 2012 -Version 1.2 CNSG007 CNSG 008 and CNSG 012 guidelines updated for
NPSA/2012/RRR001 alert compliance.
June 2015 – Version 1.3 Guidelines reviewed
April 2016 – Version 1.4 Addition to NG insertion and monitoring chart – to add ‘decision
maker, name, date and time’.

GUIDELINES FOR INSERTION AND MANAGEMENT OF NASOGASTRIC TUBES
INDEX
Section Contents Page
1.0 Definition 5
2.0 Indications 5
3.0 Contraindications 5
4.0 Assessment 6
5.0 Referral 6
6.0 Consent 6
7.0 Types of tubes and tube selection 7
8.0 Insertion of nasogastric tubes 8-10
8.1 Procedure 8-10
9.0 Confirmation of position 11-15
9.1 pH Testing 12
9.1.1 Obtaining and checking aspirate 12-13
9.1.2 Methods for successfully obtaining gastric aspirate 13
9.1.3 Recommended pH strips and usage 13
9.1.4 PH Values 13
9.1.5 Documentation of pH result 13
9.2 X-ray testing 13-14
9.2.1 When to X-ray 13
9.2.2 How to X-ray 14
9.2.3 Who should read the X-ray 14
9.2.4 Documentation of X-ray 14
9.3 Who should check the position of the tube 14
9.4 When to check the position of the tube 15
9.5 Unsafe methods for checking NG position 15
10.0 Management of a nasogastric tube 16
10.1 When to replace a should a nasogastric tube 16
10.2 Securing a nasogastric tube 16
10.3 Flushing 16
10.4 Blocked tube 16
11.0 Nasal care 16
12.0 Mouth care 17
13.0 Removal of a nasogastric tube 17
13.1 Planned 17
13.2 Accidental 17
13.3 Repeated unplanned removal 17
14.0 Escalation procedure for patient requiring NG tube
insertion
18
15.0 Discharge of patients on NG feeding 19
Appendix 1 References and bibliography 20-21
Appendix 2 Links to supporting documents
 Nasogastric insertion and monitoring form
 NPSA alerts relating to NG use
 Manufacturer’s information
 Patient information
22
Appendix 3 Algorithm to check NG position 23-24
Appendix 4 Flow chart to guide decision making for tube feeding route 25
Back to main index

1.0 DEFINITION back to index
A Nasogastric (NG) tube is a flexible tube that can be inserted transnasally into the stomach. It is
commonly used for delivery of feed, fluids, medication, or drainage of gastric contents.
Table 1
ADVANTAGES DISADVANTAGES COMMON
COMPLICATIONS
RARER
COMPLICATIONS
 Readily available
 Easily inserted
 Easily reversed
 Rapid start of enteral
feeds
 Few contraindications
to placement
 Easily
dislodged
 Uncomfortable
 Aesthetically
displeasing
 Pulmonary
intubation
 Pulmonary
aspiration
 Reflux
 Nasal and
mucosal
ulceration
 Epistaxsis
 Gastrointestinal
bleeding
 Oesophageal gastric
and duodenal
perforation
 Pneumothorax
2.0 INDICATIONS back to index
Nutritional support and hydration.
Nasogastric feeding is the most common method of providing short-term artificial nutritional
support in the acute setting. Decision to feed with a nasogastric tube should be a multidisciplinary
approach.
NG tube feeding should be considered for patients who: -
 are malnourished.
 have a functioning gastrointestinal (GI) tract.
 require short-term tube feeding (up to 4-6 weeks).
 require long-term tube feeding (if an alternative route is inappropriate or not possible i.e.
Percutaneous Endoscopic Gastrostomy (PEG) Radiologically Inserted Gastrostomy (RIG) or
Parenteral Nutrition (PN).
 are unable to fulfil their nutritional requirements with normal /modified diet  nutritional
supplements.
 are not predicted to fulfil their nutritional requirements with normal / modified diet  nutritional
supplements.
 have increased nutritional requirements e.g. sepsis, trauma, post-op stress & burns.
See appendix 5 for flow chart to guide decision making for tube feeding route
3.0 CONTRAINDICATIONS back to index
Table 2
Absolute Relative
 Non-functioning GI tract e.g. ileus.
 Large gastric aspirate and/or high risk of
aspiration.
 Intractable vomiting not resolved by anti-emetics.
Basal skull fracture, as the tube may enter the
brain if incorrectly positioned (oro-gastric
positioning may be appropriate).
 Oesophageal varices
 Mucositis
 Vomiting responding to anti-emetics
 Recent radiotherapy to head and neck
 Advanced neurological impairment
 Obstructive pathology in oropharynx or
oesophagus preventing passage of the
tube e.g. stricture, tumour, pharyngeal
pouch. Procedure may need to be
done under endoscopic or fluoroscopic
control. Specialist input advised.

4.0 ASSESSMENT back to index
Before a decision is made to insert a nasogastric tube, an assessment is undertaken to identify if
nasogastric feeding is appropriate for the patient, and the rationale for any decision is recorded in
the patient’s medical notes.
 The decision to insert a nasogastric tube for the purpose of feeding must be made following
careful assessment of the risks and benefits by at least two competent health care
professionals including the senior doctor responsible for the patient’s care.
 The decision to initiate enteral feeding should involve the patient, carer/family, and
members of the multi-disciplinary team including speech and language therapists and
dietitians as appropriate.
 The patient must be assessed for the most suitable route of enteral feeding e.g. stomach or
small bowel and most suitable type of tube.
The indication and rationale of the route and type of tube for enteral feeding will be clearly written
in the patient’s medical notes. As a minimum, documentation should include signed, dated and
timed entry, of the process of initial risk assessment that evaluates the benefits against the risks of
introducing a nasogastric tube for the purpose of feeding.
The following group of patients are at a high risk of incorrect tube positioning, dislodgement and
aspiration. Appropriate specialist advice should be taken if the patient has:
 Maxillo-facial disorders
 Laryngectomy
 Recent radiotherapy to head and neck
 Any disorder of the oesophagus/pharynx e.g. varices, stricture, pharyngeal pouch.
 Nasal C.P.A.P.
Oro-gastric positioning may be indicated following head injury or neuro surgery.
High Risk also includes patients who: -
 Are comatose/semi-comatose
 Are ventilated/sedated
 Have a swallow dysfunction
 Have recurrent retching/vomiting
 Need to be nursed prone
5.0 REFERRALS back to index
 All patients requiring NG feeding should be referred to a dietitian. This may not be possible if
the decision to feed is made out of hours. In this case the dietetic referral should be phoned
through to the dietetic answer machine x1126.
 Patients with the any of the above conditions or requirements as seen above in section 4
above will be referred a Trust employee with expert knowledge of insertion of NG tubes.
6.0 CONSENT back to index
Informed consent must be obtained from the patient prior to the procedure as per Trust policy for
consent. The consent must be recorded in the patient’s medical notes. If the patient lacks capacity
for consent, the decision to treat must be made within the patient’s best interests. The goals of the
treatment should be clearly identified in the patient’s medical notes. The procedure should also be
discussed with the family where appropriate.

7.0 TYPES OF TUBES AND TUBE SELECTION back to index
Nasogastric tubes are manufactured in a range of sizes and materials (polyvinal chloride (PVC),
polyurethane and silicone.
Feeding tubes must comply with: -
1. National Patient Safety Alert (NPSA) 19 (2007) Promoting safer measurement and
administration of liquid medicines via oral and other enteral routes.
 Enteral feeding systems should not contain ports that can be connected to intravenous
syringes, or that have end connectors that can be connected to intravenous or other
parenteral lines.
 Enteral feeding systems should be labelled to indicate the route of administration.
2. National Patient Safety Alert (NPSA 2011) Reducing the harm caused by misplaced
nasogastric feeding tubes in adults, children and infants.
 The tubes should be fully radio-opaque with externally visible markings to enable accurate
measurement, identification and documentation of their position (NPSA 2011).
NB. PVC tubes (e.g. Ryles) are not recommended for feeding as they harden in contact with
gastric acid and can cause internal ulceration (Payne-James et al 2001). In addition, they do not
comply with NPSA guidance.
Recommended tube size
8 Fr - recommended for standard use
10Fr - recommended if large volumes of medication are required via the tube (increased risk of
blockage).
Rationale for use of fine bore feeding tube
 More comfortable
 Less likely to interfere with eating and drinking
 Less risk of reflux
 Less likely to delay the return of swallowing mechanism
Guidewires
Fine bore tubes usually have a guidewire to aid insertion. The manufacturer’s guidance should be
adhered to, primarily, to ensure the guidwire is firmly positioned prior to use and never reinsert the
guidewire whilst the tube is within the patient.
back to index

8.0 INSERTION OF NASOGASTRIC TUBES back to index
The procedure will be carried out by an appropriate healthcare professional who has received
training in the procedure and has been assessed as competent. More advanced skills may be
required if the patient is at a high risk of a tube being misplaced during insertion (see section 4)
Additional training or expert input should be sought if required.
Placement should be delayed if there is insufficient experienced support available to
accurately confirm nasogastric tube placement (e.g. at night), unless clinically urgent, and
that the rationale for any decisions made is recorded in the patient’s medical notes.
8.1 Procedure back to index
Equipment
Clinically clean surface, CE accredited pH indicator strips, tissues, 60ml enteral/oral syringe,
gloves/apron, nasogastric tube.
Freshly drawn tap water to flush the tube once position confirmed.
Lubricating Jelly (may not be necessary if the tube has a water activated lubricant coating e.g.
Corpak Corflo tubes
Nasal/cheek dressing to secure tube (included in some packs).
Glass of water/coloured fluid and a straw (only if the patient has a safe swallow reflex)
Table 3
Action Rational
Prior to the procedure, check the medical and
nursing notes for complications, e.g.
anatomical variations due to surgery or
cancer.
These may affect the procedure and result in
further complications.
Patients with head injury or facial trauma may
have the feeding tube passed through the mouth
and down into the stomach to bypass nasal
damage and cerebral oedema.
Assess the patient’s requirements. The appropriate tube is inserted to meet the
patient’s needs and clinical condition and that the
tube is acceptable and comfortable.
Explain the procedure to the patient (even if
the patient appears not to understand).
To ensure that the patient understands and is able
to give consent, also to co-operate with the
procedure.
Arrange a signal so that the patient can
communicate with the nurse during the
procedure e.g. raise a hand.
Helps to alleviate fear as the patient has some
control over the procedure.
Assist the patient in a semi-upright position.
Support the head in a slightly forward
position.
Assists swallowing and helps prevent tracheal
placement if the swallow is compromised.
Check that the nostrils are patent by asking
the patient to sniff with one nostril closed.
Repeat with the other side.
Alternate nostrils if replacing a tube.
Helps identify potential obstruction.
Prevents nasal irritation and potential ulceration.
Wash hands and put on non-sterile gloves
and an apron.
Minimises cross infection (Anderton 1995).
Unpack the tube, close the end connectors. If
the tube has a guide wire, gently push it into
the tube until it is fixed (see manufacturer’s
guidelines in packet).
Check that the tube is not kinked.
Prevents the tube from coiling back on itself during
insertion.

Table 3 continued
Action Rational
Place the tip of the tube (the distal opening, if
the tube is weighted) at the xiphisternum and
measure up to the tip of the nose and then to
an ear lobe (NEX measurement). Note the
measurement on the tube.
Ensures that the correct length of tube is placed in
the stomach.
Lubricate the tube. Use a thin coating of
water based jelly. If the tube is hydrophilic
e.g. Corpak Corflo immerse the distal end
of the tube in water to activate the lubricant.
If re-passing a Corflo, use a lubricant.
Facilitates easy passage of the tube.
Insert the tip of the tube into the chosen
nostril, advancing it, horizontally, gently along
the floor of the nostril, parallel to the nasal
septum, to the nasopharynx and then
oropharynx. The patient may sneeze.
Reassure.
If resistance is met, withdraw slightly and
alter the angle of insertion, otherwise try the
other nostril.
Follow the natural anatomy of the nose.
If the patient is able to swallow small sips
should be taken at this stage. An assistant
may be required to help give thickened fluids
to swallow.
The swallowing action places the epiglottis over
the trachea so allowing the tube to enter the
oesophagus. Also the patient has something else
to focus on.
If liquids are contra-indicated, sometimes
placing a cold spoon on the tongue may
initiate a swallowing reflex.
Advance the tube down the oesophagus with
successive swallows until the correct
measurement or mark is seen at the nostril.
If the tip of the tube is in the oesophagus there is a
high risk of aspiration. If too much tube is inserted
it might kink in the stomach, or pass through the
pylorus into the duodenum.
Check the position (see section 9.0 below) To verify position in the stomach
NB
 DO NOT FLUSH the tube before gastric
placement has been confirmed.
 Internal guidewires/ stylets should NOT
be lubricated before gastric placement
has been confirmed.
Water activation of the lubricant may give an
inaccurate low pH result. NPSA/2012/RRR001
Fix the tube in position (See section 10.2) Helps prevent dislodgement.
NB. This should be done after successful verification of the tube’s position, as it may need to be
moved to obtain aspirate. If X-ray is required, the tube should be secured to the nose/cheek.
back to index

Table 3 continued back to index
CAUTION
 Never advance the tube against resistance, pull back slightly and retry.
 If the patient shows signs of respiratory distress i.e. coughing gasping or cyanosis, the
tube may have entered the trachea. Pull the tube back or remove to allow time to
recover. If respiratory distress is prolonged or worsens, seek medical assistance.
Top tips (expert opinion): back to index
 Hold the tube straight rather than coiled in your hand.
 If the patient has a swallowing difficulty, altered consciousness or inability to cooperate:
a) rotate the tube in your hand so that the tip points slightly upwards. This will position the
tip in the correct position on the nasopharyngeal wall.
b) tip the patient’s chin towards the chest.
c) advance the tube through the nostril and into the nasopharynx until resistance is felt
(usually 12-14cm marking on tube), there may be an involuntary swallow reflex
stimulated by the tube. Advance the tube with the swallow. If no reflex, advance the
tube slowly or the tube will back up into the mouth. Gentle pressure will allow the tube
to pass into the oesophagus.
If after 3 attempts NG insertion has failed or pulled out by the patient on three consecutive
occasions, escalate as soon as possible to an experienced practitioner (senior
nurse/clinician/nurse specialist).
Action Rational
Document
 Type of tube, size and lot number
 Name of person inserting the tube
 The cm measurement on the tube at the
exit point from the nostril.
 The pH value (if gastric aspirate obtained)
 Which nostril
 The health care professional (HCP)
reading the X-ray should record the result
in the patient’s notes (See section 9.2.4 for
further guidance)
 Ease of insertion
 Tracking and traceability
 For audit and training requirements
 Allows the user to assess whether the tube
has changed position.
 Allows staff to compare with previous
readings
 Prevents the same nostril being used
 To identify whether the tube is safe for use.
 For tracking and accountability.
 Useful information for other healthcare
professionals inserting subsequent tubes.
Dispose of clinical waste as per Trust policy.
The guide wire must be placed in the sharps
bin.
Prevent contamination and sharps accident.
Wash hands as per Trust policy Minimise risk of contamination

9.0 CONFIRMATION OF TUBE POSITION back to index
 NOTHING should be introduced down the tube before gastric placement has been
confirmed;
 DO NOT FLUSH the tube before gastric placement has been confirmed;
 Internal guidewires/ stylets should NOT be lubricated before gastric placement has been
confirmed.
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441
 pH testing is used as the first line test method, with pH between 1 and 5.5 as the safe
range, and that each test and test result is documented on a chart kept at the patient’s
bedside.
 An attempt at pH testing must be carried out following every nasogastric tube insertion
even if the criteria for x-ray testing are met. This will allow for a baseline recording.
Studies suggest a 90% + success rate in obtaining aspirate.
 X-ray is used only as a second line test when no aspirate could be obtained or pH
indicator paper has failed to confirm the position of the nasogastric tube.
NPSA/2011/PSA002 alert: Reducing the harm caused by misplaced nasogastric feeding tubes in
adults, children and infants.
9.1 pH Testing back to index
9.1.1 Methods for successfully obtaining gastric aspirate
Aspiration of gastric contents is sometimes difficult. The table below offers suggestions. A
combination of these may be required. Refer to algorithms 1 and 2 in appendix 3 for further
guidance. Patience is required.
Table 4
ACTION RATIONAL
Always use a large enteral syringe (50cc min). Small syringes have insufficient draw.
 Insert 20 – 30mls of air, then aspirate.
 Repeat several times, aspirating after each
injection of air.
 If unable to aspirate air, move the tube in or out
until air is returned. Usually a small amount of
fluid will be returned with the air (0.5mls is
sufficient to cover the pH strip).
The most common position for a return of aspirate is
when the tube markings show between 52-60cm at
the exit from the patient’s nose (expert opinion).
 Pushes the tube away from the gastric
mucosa, which may occlude the tube.
 Allows the stomach to inflate and
redistribute the position of fluid slightly
(Colagiovanni 1999).
Lie the patient on their left side. Gastric fluid will pool in a different position.
Alter the position of the tube and retry. The tube may be positioned insufficiently,
or too far into the stomach.
Flush the tube with water following aspiration Gastric acid causes the protein in the feed
to coagulate and increases the risk of tube
blockage.

9.1.2 Recommended pH strips and usage
 Tube position must be checked using pH indicator strips that are CE marked, intended by the
manufacturer to test human gastric aspirate and have a clear definition between pH 5-6 (NPSA
2005, 2011).
 pH strips must be used and stored according to manufacturer’s instructions. The reagent
section should not be contaminated before use through handling or inappropriate storage.
 It is not accepted practice to put gastric aspirate onto the syringe wrapping/cover and then to
run reagent strips through the aspirate. This may alter the pH reading (NPSA 2005).
NB.
 The lids must be kept on the containers when not in use.
 One box per patient – sharing has a high risk of cross contamination.
 The box must be decontaminated once it is no longer required for a patient.
back to index
9.1.3 pH Values
A pH of less than 5.5 is a reasonable indicator of gastric placement. (NPSA 2005)
The pH of pulmonary fluid is normally above 6
The pH of intestinal fluid is normally above 6
Gastric pH levels may be elevated above 5.5 due to: -
a) Medication i.e. H2 antagonists and proton pump inhibitors which inhibit or reduce acid
production; antacids temporarily reduce gastric acidity by neutralising hydrochloric acid.
b) Reflux of intestinal contents into the stomach (Metheny et al 1994b).
c) Dilution of gastric acid due to:
 recent feed/flush: wait half an hour and retry.
 continuous feeds: consider stopping the feed for half an hour (Colagiovanni 1999).
CAUTION: Stopping feed should be carried out with extreme caution for patients on insulin
infusions for tight glycaemic control and only if other methods have failed. Stop insulin
infusion whilst the feed is turned off (NPSA 2005).
If aspirate values are higher than normal, it can be hard to assess the position of the tube. Using
algorithms 1 and 2 in appendix 3 will help individuals to assess and rationalise their decision
making in order to make NG tube management as safe as possible.
9.1.4 Documentation of pH result
Each pH test and result must be documented on the nasogastric monitoring form kept at the
patient’s bedside.
back to index

9.2 X-Ray testing
Table 5
Method Advantages Disadvantages
X-ray
2nd
line testing
method. See section
9.2 for indications
This is the most
accurate method of
confirming
positioning.
 No guarantee that the tube is still in position once the
patient has returned to the ward and for the subsequent
duration of NG feeding.
 Risk of frequent exposure to X-rays.
 Delay in commencing feeding via the tube.
 Cost and resource implications.
 Impractical for patients based in the community
9.2.1 When to X-ray back to index
X-ray following insertion is only indicated if:
 The patient is unconscious with no gag reflex (ICU protocol).
 The patient has altered anatomy e.g. known large hiatus hernia, pharyngeal pouch, previous
surgery on the upper GI tract.
 There is absence of aspirate
 pH testing is inconclusive.
 Difficult tube insertion.
 Fractured base of skull.
 Recent radiotherapy to head and neck.
 Recent surgery to head and neck.
X-ray should not be used routinely to confirm tube position during subsequent use. If you are
unable to confirm position using the above guidelines, refer to algorithms 1 and 2 in appendix 1
for further guidance for checking the tube position following failure to obtain aspirate or
inconclusive pH values.
An attempt at pH testing must be carried out following every nasogastric tube insertion even if the
criteria for x-ray testing are met. This will allow for a baseline recording.
Studies suggest a 90% plus success rate in obtaining aspirate.
(NPSA 2011).
9.2.2 How to X-ray back to index
When ordering an X-ray check, the request form must clearly state that the purpose of the x-ray is
to establish the position of the nasogastric tube for the purpose of feeding.
The radiographer is responsible for: -
 Ensuring that the nasogastric tube can be clearly seen on the x-ray to be used to confirm
tube position.
 Adjusting the exposure of the x-ray to allow the nasogastric tube to be visible to the bottom
of the film.
 Ensuring that the film is centred lower than would normally be appropriate for a chest x-ray
so that it shows the abdomen as far as possible below the diaphragm.
 Adjusting the x-ray film to show the bottom of both hemi-diaphragms in the midline.

X-rays that are not as described above will not allow accurate interpretation of nasogastric tube
placement and should not be allowed out of the x-ray department.
If there is any difficulty in interpretation the advice of a radiologist should be sought.
Any nasogastric tubes identified to be in the lung should immediately be removed whether in the x-
ray department or clinical area.
9.2.3 Who should read the X-ray? back to index
X-rays must be checked by an appropriately trained clinician/advanced nurse practitioner, with
evidence to support this skill.
9.2.4 Documentation of X-ray
Documentation following X-ray should include:
 who authorised the x-ray
 who confirmed the position of the nasogastric tube. This person must be evidenced as
competent to do so
 confirmation that any x-ray viewed was the most current x-ray for the correct patient
 the rationale for the confirmation of position of the nasogastric tube, i.e. how placement was
interpreted, and clear instructions as to required actions. For example:
19 January 2011, 10:30 – Dr A. Smith – core surgical trainee
X-ray taken at 10:15 today
NG tube passed down midline, past level of diaphragm and deviates to left
Tip is seen in stomach
Plan: NG tube safe to use for feeding
Dr A. Smith
9.2.5 Cautions
 There is no guarantee that the tube is still in position once the patient has returned to the ward
and for the subsequent duration of NG feeding. The tube position i.e. centimetre marking at the
tube’s exit from the nostril, should be checked and compared with the position post insertion,
by the member of staff using the tube immediately prior to use.
 Risk of frequent exposure to X-rays.
 Delay in commencing feeding via the tube.
 Cost and resource implications.
 Impractical for patients based in the community
9.3 Who should check the position of the tube? back to index
 Any health professional/carer/patient prior to using the tube.
 In the majority of cases nurses pass the tube and manage subsequent feeding. A nurse may
be involved in training a patient/carer to manage the tube.

9.4 When to check the position of the tube back to index
After initial tube insertion
 At least once per shift if continuous feeds are in progress
 Before each bolus feed, fluid or drug administration.
 If the patient complains of discomfort or feed reflux in the throat or mouth.
 If the patient suddenly shows signs of respiratory distress, e.g. breathlessness, strider,
cyanosis or wheezing.
 Vomiting or violent retching.
 Severe coughing bouts.
 If the measurement marking the tube’s exit from the nose has changed.
 If the tube length appears to have changed.
 Following transfers from other clinical areas if feed in progress.
9.5 Unsafe methods for checking NG position back to index
Table 6
METHOD REASON WHY UNSAFE
Auscultation – the injection of 20 –30mls of air
into the tube via a syringe whilst listening with a
stethoscope over the left upper quadrant or
epigastrium for a distinctive sound whooshing
sound.
 Auscultation cannot predict whether tube tip
location is in the oesophagus, stomach or
respiratory tract (Metheny et al 1990a and
Neumann and Meyer 1995).
 Unsuitable for obese patients, as no sound
may be heard.
 There are reported cases showing that NG
tubes checked by air auscultation were later
shown to have tracheopulmonary
placement. (Rassias et al 1998).
 Eleven deaths reported between 2002-2004
due to misplaced NG tubes following
auscultation tests and using litmus paper
(NPSA 2005, Colagiovanni 1999).
Checking ability to speak Fine bore tubes are small enough not to affect
speech
Signs of respiratory distress  Fine bore tubes might not cause respiratory
distress.
 Patients with a poor gag reflex, or altered
consciousness might not demonstrate these
signs.
Using Litmus paper to test aspirate  Insufficiently accurate
 Turns pink/red in contact with aspirate that
has a pH value as high as 6.5 (NPSA 2005).
Placing the proximal end of the nasogastric
tube in water and watching for bubbles to
indicate placement in the lungs. If no bubbles,
the tube is in the stomach.
 Inaccurate and unsafe (Colagiovanni 1999).

10.0 MANAGEMENT OF A NASOGASTRIC TUBE back to index
10.1 When to replace a nasogastric tube
Refer to manufacturer’s guidelines and individual patient assessment.
Table 7
TUBE TIME
Ryles tube
Used for aspiration
only
10 days, or sooner, if causing discomfort (Dougherty and Lister 2004)
Corpak Corflo
tube
The manufacturers of Corflo tubes do not state a time limit for usage and
suggest that they can be used as long as they are functional. (Merck
communication). Decision to replace will depend on: -
 Viability of the tube
 Tolerance of the procedure by the patient
 Difficulty in insertion
Other tubes Check with manufacturer/nurse specialist
10.2 Securing a nasogastric tube back to index
 The tube should be fixed at the nose with a plaster.
 If tube has already been accidentally removed on multiple occasions a nasal retention device
(bridle) should be considered (NICE Clinical Guidelines (32)
 2006) . .See Guidelines for Insertion and Management of Nasal Bridles for further
information.
 The external part of the tube should be brought to the same side of the face as the insertion
nostril and allowed to rest over the ear.
- A dressing (preferably clear for aesthetic reasons) should be placed over the tube along
the cheek. This is recommended for the following reasons: Less irritating for the patient
as it secures the tube out of their line of sight.
- Does not interfere with the patient’s eating, by keeping the tube away from the mouth.
- A confused patient is less likely to pull the tube out as they cannot see it or feel it when
they bring their hands up to the mouth area.
- Patients receiving humidified oxygen (excess moisture makes the nasal tape slip).
 The dressings should be checked regularly and replaced if dirty or peeling off.
 The skin should be cleaned of any residual adhesive prior to replacing the tape/dressing.
10.3 Flushing back to index
Refer to CNSG 013 Guidelines for Administration of Feed and Fluid via Enteral Tubes.
10.4 Blocked tube
See CNSG 014 Guidelines for Enteral Feeding Complications and Management.
11.0 NASAL CARE
 The nose should be checked and cleaned daily.
 If the nose appears sore or ulcerated, consider re-passing the tube via the other nostril.
back to index

12.0 MOUTH CARE back to index
Maintenance of oral hygiene is essential, particularly is a patient is unable to
 have oral food and fluids
 attend to their own oral care
Table 8
PROBLEM REASON ACTION
Dry sore mouth  Inadequate mouth care
 Mouth breathing
 Poor dental condition
 Clean teeth/dentures with a soft toothbrush
or a damp swab wrapped around a gloved
finger (depending on patient). The frequency
will depend on the condition of the patient,
twice daily minimum).
 Check the tongue and the hard palate for
thickened secretions and remove.
 Use lip salve to protect lips from chapping.
 Consider use of artificial saliva if appropriate
 Refer to dentist if necessary.
Saliva : -
Tenacious
Hyper-salivation
 Dehydration
 Neurological condition
 Unable to swallow oral
secretions
 Ensure adequate fluids.
 Consider drug therapy. Consult doctor.
 Maintain good oral hygiene.
Refer to Guidelines for the Oral Healthcare of Stroke Survivors by the British Society of
Gerodontology for comprehensive guidance as to management of oral hygiene.
http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf
13.0 REMOVAL OF A NASOGASTRIC TUBE
13.1 Planned
The patient must be referred to the dietitian prior to discontinuation of enteral feeding for review as
to whether oral intake is sufficient and whether oral supplements may be required.
13.2 Accidental
If the tube is still required for nutrition, fluids or medication, it should be reinserted as soon as
possible – within a 6 hour period is recommended. See below for Escalation Procedure (section
14.0) for patient requiring NG tube insertion. In addition: -
 Ensure that the tube is correctly positioned and secured, as above, when reinserted.
 Arrange for alternative fluid support as necessary.
 Arrange for an alternative route for medication as appropriate.
13.3 Repeated unplanned removal
If unplanned removal is repeated, refer to CNSG 008 Nasal Bridle guidelines Appendix 1 flow
chart to manage repeated unplanned removal of nasogastric tube.
back to index

14.0 Escalation procedure for patients requiring NG tube insertion with or without
introducer.
back to index
Patient requires NG tube
Competent nurse
unavailable
Competent Medical
F1/F2 to insert
F1 /F2 unavailable or
do not have skill to
insert within two hours
of request: Escalate
Competent Nurse
identified and inserts
as per Trust
Guidelines for
Insertion and
Management of
Nasogastric Tubes
Fully document
procedure in medical
and nursing notes
NG tube becomes
 Blocked
 Dislodged
 Accidentally
removed
Refer to competent
nurse within area if
unavailable escalate
Escalate to:
In hours
 Senior nurse
/Matron for area.
 MNP/PSP
 Registrar
 GI specialist nurse
 Outreach team
Out of hours
 Senior nurse for
area
 Hospital senior
nurse/Night sister
 Registrar
Competent in the
procedure
Matrons Sam Leonard and Hayley Readiing August 2010

15.0 Discharge of patients on NG feeding
Patients must have prior to discharge: -
 A multidisciplinary risk assessment to assess needs (Appendix 5 Flow chart to guide
decision making for tube feeding route)
 Referral to a dietitian
 Training and assessment of competency for them and/or their carers for tube care and
feeding.
 An agreed plan if tube removed accidentally or blocked.
 A discharge pack to include: -
o Care of NG tube
o Care of equipment
o Contact numbers
o Feeding regimen
o Position monitoring form
o CE accredited pH strips
o Manufacturer’s guidelines for using pH strips
o Spare NG tube
o 7 days feed and equipment
o How to maintain oral hygiene
Action plan if tube removed
The plan will depend on the patient’s circumstances and the support available in the community
 If tube comes out overnight wait until daytime for replacement
 If the patient has had recent radiotherapy treatment at Christie, they will be at a high risk of
procedure related complications. In the absence of specialist support, refer them back to
Christie hospital.
 If the patient has head and neck cancer and has had treatment at Leighton hospital, they
have open access to ward 10 and should return there for tube placement.
 Any other patients should come to come to A&E bringing their spare tube with them.
back to index

APPENDIX 1 - REFERENCES AND BIBLIOGRAPHY back to index
Anderton A. (1995). Reducing bacterial contamination in enteral tube feeds. British Journal of
Nursing 4(7); 368-376
BAPEN (2004). Drug administration via enteral feeding tubes. A Guide for General Practitioners
and Community Pharmacists. British Association for Parenteral and Enteral Nutrition, Maidenhead.
BAPEN (1996) Standards and Guidelines for Nutritional Support in Hospitals (ed. T. Sizer). British
Association for Parenteral and Enteral Nutrition, Maidenhead.
Boyes, R.J., Kruse, J.A. (1992) Nasogastric and nasoenteric intubation. Critical Care Clinics 8(4):
865-867.
British Society of Gerodontology (2010) Guidelines for the Oral Healthcare of Stroke Survivors.
http://www.gerodontology.com/content/uploads/2014/10/stroke_guidelines.pdf
Colagiovanni L. (1999) Taking the tube. Nursing Times 95:21 Supplement.
Colagiovanni L. (2000) Preventing and clearing blocked feeding tubes. Nursing Times. 96(17): 3-4.
Dougherty, L. & Lister S. (eds) (2004) The Royal Marsden Manual of Clinical
Nursing Procedures, 6th edn. Blackwell Science Ltd, Oxford.
Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in
Partnership with Nutricia.
Fater, K.H. (1995) Determining nasoenteral feeding tube placement. MedSurg Nursing, 4(1): 27-
32.
Human Rights Act 1998
Medicines and Healthcare products Regulatory Agency (MHRA 2000) Single-use Medical Devices:
Implications and Consequences of Reuse. MDA DB2000(04)
Medicines and Healthcare products Regulatory Agency (MHRA 2000) Enteral Feeding Systems.
MDA SN2000(27).
Medicines and Healthcare products Regulatory Agency (MHRA2004) Enteral feeding tubes
(nasogastric) MDA/2004/026
Mental Capacity Act 2005
Metheny N. et al. (1990a) Detection if inadvertent respiratory displacement of
small bore feeding tubes: a report of 10 cases. Heart Lung 19(6): 631-638.
Metheny N. et al. (1990b) Effectiveness of the ausculatory method in predicting feeding tube
location. Nursing Research 39:262-7.
Metheny N. et al. (1993) How to aspirate from small bore feeding tubes. American Journal of
Nursing, May 86-89.
Metheny N. et al. (1993) Effectiveness of pH measurements in predicting feeding tube placement:
an update. Nursing Research 42(6): 324-331.
back to index
back to index

Metheny N. et al. (1994a) Visual characteristics of aspirates from feeding tube as a method for
predicting tube placement. Nursing Research 43(5): 282-287.
Metheny N. et al. (1994b) pH testing of feeding tube aspirates to determine placement. Nutrition in
Clinical Practice 9(5): 185-190.
National Institute for Clinical Excellence (NICE) (2013) Nutrition support in adults
Evidence Update August 2013. A summary of selected new evidence relevant to NICE clinical
guideline 32 ‘Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral
nutrition’ (2006) Evidence Update 46
National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation
of placement NPSA/2012/RRR001 22/03/12
National Patient Safety Agency (2011) Reducing the harm caused by misplaced nasogastric
feeding tubes in adults, children and infants. NPSA/2011/PSA002
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640
National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes NPSA/2007/19
feeding tubes NPSA/2005/05
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59794&p=4
National Institute for Clinical Excellence (NICE) (2012) clinical guideline 139
Infection Prevention and control of healthcare-associated infections in primary and community care
http://guidance.nice.org.uk/CG139
National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral
supplements, parenteral and enteral feeding. London.
http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf
Neumann M.J., Meyer C.T. (1995) Hold that X-ray: aspirate pH and auscultation prove enteral tube
placement. Journal of Clinical Gastroenterology 20(4): 293-295
Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour
for nurses and midwives. London, NMC.
Payne-James, J., Grimble, G. & Silk, D. (2001) Enteral nutrition: tubes and techniques of delivery.
In: Artificial Nutritional Support in Clinical Practice, 2nd edn (eds J. Payne-James, G. Grimble & D.
Silk). Greenwich Medical Media, London.
Powell K.S. et al (1993) Aspirating gastric residuals causes occlusion of small bore feeding tubes.
Journal of Parenteral and enteral Nutrition. 17(3): 243-246
Rassias A.J. et al (1998). A prospective study of tracheopulmonary complications associated with
the placement of narrow bore feeding tubes. Critical Care 2: 25-28.
back to index

APPENDIX 2 LINKS TO SUPPORTING DOCUMENTS/NG CAREPLAN
back to index
NASOGASTRIC (NG) TUBE INSERTION AND MONITORING FORM – click on to access.
Patient Information leaflets
Drug administration via enteral feeding tubes
http://www.bapen.org.uk/pdfs/d_and_e/de_pat_guide.pdf
NPSA alerts relating to Nasogastric feeding
Manufacturer’s websites
Abbott Nutrition home page – access to pump instruction manuals and training
Videos
http://www.abbottnutritionuk.com/
Corpak Medsystems – access to information about enteral tubes and company guidelines
http://corpakmedsystemsuk.com/
Medicina – information about enteral syringes and feeding devices
http://www.medicina.co.uk/
back to index

APPENDIX 3 ALGORITHM 1 - TO CONFIRM NG POSITION FOLLOWING INSERTION AND PRIOR TO USE
No
Yes Yes
No
Yes
Yes
No
NG TUBE
?
IN POSITION
ASPIRATE
OBTAINED?
TRY A
COMBINATION OF
THE FOLLOWING
pH 6
OR
ABOVE
?
TEST ON pH
PAPER
See box A
pH 5.5
OR
LESS?
ASPIRATE
OBTAINED?
FLUSH 20-30MLS AIR WITH A SYRINGE
THEN ASPIRATE
REPEAT 2-3 TIMES
ALTER TUBE POSITION SLIGHTLY
Aspirate is most commonly obtained when the
tube is positioned between 52-60cm (mark at
exit from nose)
IF UNSUCCESSFUL REPEAT INSERTION OF
AIR AS ABOVE
ALTER POSITION OF PATIENT - TURN ONTO
LEFT SIDE AND REPEAT AS ABOVE
CONSIDE
R
COLOUR OF
ASPIRATE
Yellow/green stained
aspirate is suggestive
of bile (higher pH)
IF NEW INSERTION - X-RAY
(see box C)
IF ROUTINE CHECK - REFER TO
ALGORITHM 2 FOR
INCONCLUSIVE ASPIRATE -
ACTION B
X-RAY
CHECK
See box C
IF NEW INSERTION - X-RAY
(see box C)
REFER TO ALGORITHM 2 FOR
ACTION C
RECENT FEED
IF TUBE IS IN THE LUNG REMOVE AND START
AGAIN
IF IN GI TRACT BUT IN INCORRECT PLACE,
REPOSITION AS PER EXPERT CLINCAL GUIDANCE.
Box C. X-RAY FOLLOWING INSERTION IS INDICATED FOR THE FOLLOWING HIGH RISK
GROUPS:
1. Unconscious with no gag reflex (ICU protocol) 4. Difficult insertion
2. Altered anatomy e.g. known large hiatus hernia 5. Fractured base of skull
3. Testing of aspirate is inconclusive 6. Recent radiotherapy/surgery to head and neck.
 X-ray should not be used routinely to confirm tube position during subsequent use. If you are unable to confirm position
using the above guidelines, see algorithm 2 for checking tube position following no aspirate or inconclusive pH values.
 When ordering X-rays, please specify ‘to check NG position’ on request form.
 X-rays must be checked by an appropriately trained clinician/advanced nurse practitioner. The result must be recorded
in the patient’s notes.
NB. High risk patients requiring X-ray following insertion should have a pH check of aspirate carried out as well, to
provide a baseline for subsequent checks.
Box A. HOW TO USE pH STRIPS
1. Place a small amount of aspirate onto the pH strip-avoid touching the area to be
read.
2. Allow 10 seconds and compare the resulting colour with the colour chart on the pH
strip container.
Box B. VARIATIONS IN GASTRIC pH MAY BE CAUSED BY:
1. Medication i.e. H2 antagonists and proton pump inhibitors which inhibit or reduce
acid production. PH value will be raised.
2. Bile/ Recent feed/Lung placement – less acidic, therefore will show a higher pH
value.
GIVE FEED, FLUID AND
MEDICATION AS
PRESCRIBED
See box C for whether
X-ray is indicated
TUBE POSITION
CORRECT ON X-RAY?
See box C.
MEDICATION
See box B
IF NEW INSERTION
WAIT ½ - 1 HOUR AND RETRY
IF NO CHANGE X-RAY
(see box C)
IF ROUTINE CHECK - REFER TO
ALGORITHM 2 FOR
ACTION D

ALGORITHM 2 - TO ASSIST IN CONFIRMING NG POSITION IF NO ASPIRATE OR PH VALUE INCONCLUSIVE
NO ASPIRATE INCONCLUSIVE ASPIRATE (Ph GREATER THAN 5.5) - COMBINE THE
FOLLOWING WITH TUBE DISPLACEMENT CHECKS.
ACTION A. CHECK FOR TUBE DISPLACEMENT ACTION A.
ACTION B.
No
No Yes
No ACTION C.
No ACTION D.
No
ACTION B. ACTION C.
ACTION E.
Yes
HAS THE EXTERNAL LENGTH OF THE TUBE CHANGED?
Check cm mark at exit from nose and compare with
insertion data on monitoring charts/NG care plan.
HAS THE PATIENT VOMITED?
HAS THERE BEEN AN INCREASE IN THE PATIENT’S
RESPIRATORY DISTRESS e.g. breathlessness, strider, cyanosis
or wheezing.
IS THE NG TUBE VISIBLE IN THE MOUTH?
IF NO CHANGE, DOCUMENT
RESULTS AND CONTINUE TO
USE THE TUBE - if unsure,
consult a senior/more
experienced member of staff.
Document decision and
rationale.
REPOSITION TUBE
OR REMOVE AND
REPLACE – repeat
confirmation checks
as seen in algorithm1
FLUSH A SMALL AMOUNT OF AIR THROUGH THE TUBE TO CLEAR RESIDUAL FEED/FLUID THEN
RETRY
MEDICATION: IF ON A PPI e.g. LANSOPRAZOLE/OMEPRAZOLE OR H2 ANTAGONIST e.g. RANITIDINE,
Look at previous pH readings, if consistently high, treat as normal, if a one off, consider why. Request
senior input.
CONSIDER DILUTION OF GASTRIC ACID.
1. RECENT FEED/FLUSH: WAIT HALF AN HOUR AND RETRY
2. CONTINUOUS FEEDS: CONSIDER STOPPING THE FEED FOR HALF AN HOUR.
CAUTION: If the patient is having insulin infusions for tight glycaemic control . Consult with senior
doctor/specialist before stopping the feed.
IF REMAIN UNSURE AFTER THE ABOVE, CONSIDER X-RAY.
Consult a senior/more experienced member of staff prior to requesting an X-ray. Document decision
and rationale.
HAS THE MARK AT THE EXIT FROM THE NOSE SLIPPED?
CONSIDER THE VOLUME OF ASPIRATE: LARGE VOLUMES SUGGEST GASTRIC PLACEMENT.
CAUTION: There have been reported high volumes of aspirates from tubes that have been located in
the lungs. Request senior input.
CONSIDER THE COLOUR OF ASPIRATE: YELLOW/YELLOWY-GREEN/DARK GREEN ASPIRATE IS
SUGGESTIVE OF BILE.
CAUTION: Lung aspirates shave been described as the above colours. Look at previous pH readings, if
consistently high, treat as normal, if a one off, consider why. Request senior input.

APPENDIX 4: FLOW CHART TO GUIDE DECISION MAKING FOR TUBE FEEDING ROUTE
back to index
PEG/nasal bridle
contraindicated or
refused by patient
If for oral feeding, refer
to SALT for safe
feeding techniques and
to dietetics for
maximising calorific
value of meals.
Consider referral for: -
 PEG feeding (see
Trust PEG
guidelines)
Start NG feeding if
appropriate whilst
waiting for PEG
insertion.
 NG tube with nasal
bridle (see Trust
nasal bridle
guidelines)
.
Enteral tube feeding support required (see indications section 2.0)
Confused and pulling out
NGT (see flowchart to
manage repeated
unplanned removal of NG
tubes)
If for NG feeding organise MDT
assessment prior to discharge to
plan:-
 Care requirements in
community
 Who will provide care
 Training required to minimise
risks
 Agree action plan if NGT comes
out
Refer to section 15.0 above
Consider: -
 Referral for radiologically inserted gastrostomy (RIG) (see section 12.0 of Trust PEG
guidelines)
 Continuing NG feeding +/- nasal bridle (unless contraindicated or refused by patient)
 Limited oral feeding with palliative care
Risk/benefit assessment required as to best modality for patient plus patient choice where possible
If for oral feeding repossible
Short term requirementLong term requirement
– more than 6 weeks
Yes
If for palliative care,
organise MDT to discuss
plan of care and refer to
relevant healthcare
professionals.
Assess for risk and
appropriateness of
nasogastric tube (NGT)
No
Refer to specialist/expert
practitioner for insertion
and management advice
Insert NGT as per Trust
guidelines
HIGH RISK of
complication
Yes

END OF EAST CHESHIRE NHS TRUST CNSG 007 GUIDELINES
FOR INSERTION AND MANAGEMENT OF NASOGASTRIC
TUBES
back to index
back to main index

East Cheshire NHS Trust CNSG 008 Guidelines for Insertion and Management of Nasal Bridles Page 27 of 172
Created by Maggie Allen, October 2010. Updated July 2015.
Guideline Title: Guidelines for Insertion and Management of Nasal Bridles
Executive
Summary:
nasogastric tube under the care of East Cheshire NHS Trust.
Description of
Amendment(s):
Guidelines reviewed - no major changes
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Committees / Group Date
Gastroenterology
October 2010-August 2011
June 2015
AMENDMENT RECORDS
August 2011 Guidelines updated for NPSA/2011/PSA002 alert compliance

GUIDELINES FOR INSERTION AND MANAGEMENT OF NASAL BRIDLES
INDEX
Back to main index
1.0 Introduction 29
2.0 Definition 29
3.0 Indications 29
5.0 Assessment and referral 30
6.0 Consent 30
7.0 Equipment 30
8.0 Procedure 30
9.0 Potential complications 31
10.0 Aftercare 31
11.0 Discharge with a nasal bridle in situ 31
12.0 Displacement within the community 31
13.0 Planned Removal 31
14.0 Disposal 31
15.0 References 32
Appendix 1 Flow chart to manage repeated unplanned removal of a
nasogastric tube
33
Appendix 2 Nasal Bridle Fixation device request form 34
Appendix 3 Flow chart to guide management if nasogastric tube or nasal
bridle displaced
35
Appendix 4 Links to supporting documents/information
 NPSA alerts relating to NG use
 Manufacturer’s websites
36

The following guidelines should be used in association CNSG 007 Guidelines for the Insertion
and Management of Nasogastric Tubes.
1.0 Introduction back to index
Nasogastric feeding is the most common method of providing short-term artificial nutritional
support in the acute setting. There is a high risk of accidental removal either by the patient or by
staff caring for the patient. Unplanned removal impacts in the following ways: -
 The patient does not meet their nutritional and fluid requirements
 The patient requires another tube placing
 Increased incidence of chest x-rays.
2.0 Definition back to index
A nasal bridle is the positioning of a tape around the nasal septum to secure a nasogastric tube
where it exits the nostril. If required, the bridle can remain in place for the duration of nasogastric
feeding. The use of a nasal bridle to secure a nasogastric feeding tube was first described in 1980
and has since been demonstrated to be safe and effective (Donaldson et al 2007).
The aim of a nasal bridle is to: -
 Prevent unplanned removal by patients and staff caring for the patient.
 Eliminate inappropriate gastrostomy insertion and associated risks.
 Maintain nutritional intake.
 Allow time for assessment as to the best method of nutritional support for a patient.
3.0 Indications back to index
Patients who require delivery of medication/feed/fluid via the enteral route with the following
criteria: -
 Poor tolerance of the nasogastric tube i.e. pulled out on at least 3 occasions in short
succession.
 Sub optimal nasal fixation tape as a result excessive moisture e.g. patient receiving
humidified oxygen therapy (tube displaced on at least 3 occasions as a result of this).
 Skin irritation caused by adhesive securing tape.
 Long term nasogastric feeding required if gastrostomy insertion inappropriate.
 Known difficult insertion procedure involving videofluroscopy or endoscopic insertion
4.0 Contraindications back to index
Patients excluded from nasal bridle placement include:
 Severely agitated patients who are likely to cause damage to their nasal septum due to
excessive pulling on the tube.
 Facial or cranial trauma.
 Basal skull fracture.
 Severely deviated, structural deformity, or obstructed nasal septum or passage.
 Nasotracheal tubes in situ.
 Advanced dementia (as well as being highly likely to pull on the tube due to confusion,
these individuals may not benefit from enteral nutrition support – see CNSG 009
Guidelines for Insertion and Management of Gastrostomy Tubes for further guidance).
 Thrombolytic therapy for acute stroke or MI in the last 5 days (relative - discuss with
consultant)
 Warfarin therapy (relative - discuss with consultant)
 Recent radiotherapy to the nose

5.0 Assessment and Referral back to index
 If the patient is pulling out a nasogastric tube, try to identify the cause
 Rule out medical reasons for confusion such as infection, dehydration.
 The decision to place a nasal bridle should be within an MDT setting
 The patient should be referred to an appropriately trained doctor or nurse for assessment
and insertion of the nasal bridle.
See appendix 1 for flowchart for recommended management plan.
6.0 Consent back to index
Informed consent must be obtained from the patient prior to the procedure as per Trust policy. The
consent must be recorded in the patient’s notes. If the patient lacks capacity for consent, the
decision to treat must be made within the patient’s best interests. The goals of the treatment
should be clearly identified in the patient’s medical notes. The procedure should also be discussed
with the family where appropriate.
7.0 Equipment
AMT nasal bridle - kept on ETU/Ward 3/Ward 11
Nasogastric tube insertion equipment (Refer to CNSG 007 Guidelines for the Management of
Nasogastric Tubes).
8.0 Procedure back to index
 The bridle must be inserted by an appropriately trained doctor or nurse.
 The patient should be prepared as per CNSG 007 Guidelines for the Management of
Nasogastric Tubes) and a nasogastric care plan completed.
 The nasogastric tube must be inserted and the position checked prior to insertion of the bridle.
National Patient Safety Agency Alert 19 guidance must be observed when assessing the tube’s
position (www.npsa.nhs.uk) Also refer to CNSG 007 Guidelines for the Management of
Nasogastric Tubes.
 Insert bridle following manufacture’s guidelines. Follow link
http://www.appliedmedical.net/amtbridle.htm for pictorial guidelines and link
http://www.appliedmedical.net/bridleVideo/bridleVideosWindow.htm for a video of
the procedure (click on the appropriate tube French size directions for use).
 When finished, dispose of clinical waste and wash hands as per Trust policy.
back to index

9.0 Potential complications back to index
Anterior epistaxis
Bleeding may occur during insertion of a nasal bridle device. Any bleeding lasting longer than 15
minutes or greater than 100mls should be discussed with the medical team.
Pressure necrosis
If the nasal bridle is fastened too tightly or becomes twisted, pressure sores may lead to necrosis
of the nasal septum. If a pressure sore develops, the bridle tape should be cut and removed (see
section 13.0 below). The area should be checked, cleaned daily and a dressing applied where
indicated. The condition of the patient’s nostrils should be recorded daily in the patient’s care plan.
Dislodged Nasogastric tubes
It is still possible for a tube to become dislodged despite a bridle, either deliberately by the patient
or accidentally during vomiting. The tube position must continue to be checked prior to each
episode of use as per CNSG 007 Guidelines for the Management of Nasogastric Tubes.
10.0 Aftercare back to index
The patient should be monitored as per CNSG 007 Guidelines for the Management of
Nasogastric Tubes. In addition, the patient should be monitored closely for signs of nasal trauma
as a result of the patient pulling on the tube, or irritation caused by the tape rubbing against the
nasal passage. The nasal passage and tape should be cleaned daily.
11.0 Discharge with a nasal bridle in situ
If the patient is to be discharged with a bridle in situ the following should be in place: -
 A written care plan provided for carers.
 Plan of action if the tube becomes displaced.
 Support from dietetics to continue with nutritional monitoring.
12.0 Displacement within the community back to index
District nurses or out of hours nurses should be contacted to assess whether the patient needs to
attend the A&E department.
13.0 Planned removal
Cut one side of the tape (usually the side exiting the nostril opposite the nasogastric tube) and pull
the nasogastric tube out. The tape will follow with the tube. See video link for a demonstration.
http://www.appliedmedical.net/bridleVideo/bridleVideosWindow.htm
14.0 Disposal
The tube and bridle should be disposed of as per East Cheshire NHS Trust policy for disposal of
clinical waste.
back to index

15.0 References back to index
Donaldson, E., Early, T., Sheilds, P (2007) The Nasal Bridle – It’s place within an integrated
nutrition service: a prospective audit of one year’s data. Gut (56) Suppl 56 A137
Johnston RD et al. (2008). Outcome of patients fed via a nasogastric tube retained with a bridle
loop: do bridle loops reduce the requirement for percutaneous endoscopic gastrostomy insertion
and 30-day mortality?
Proceedings of the Nutrition Society 67, E116.
Lancashire Teaching Hospitals NHS Trust (2006). Safe practice for insertion and management of a
nasal bridle to secure nasogastric tubes.
National Institute for Clinical Excellence (NICE) (2006) Nutrition Support in Adults: oral
supplements, parenteral and enteral feeding. London.
http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf
Russell KL et al. (2006). Bridle fixation of nasogastric tubes – the Addenbrooke’s experience.
Proceedings of the Nutrition Society 65, 14A.
Popovich MJ et al. (1996). Nasal bridle revisited: An improvement in the technique to prevent
unintentional removal of small-bore nasoenteric feeding tubes. Critical Care Medicine 24, 429-431.
back to index

APPENDIX 1. back to index
FLOW CHART TO MANAGE REPEATED UNPLANNED REMOVAL OF A NASOGASTRIC
TUBE
back to index
back to NG guidelines
Patient pulled out NG tube on more
than three occasions
Is the patient confused?Yes No
Establish reason for confusion and treat
accordingly
Reassess for a nasal bridle. MDT discussion to
discuss appropriateness. To include
Doctor/nurse/SALT/dietitian
Wait 24 hours
Identify why the patient is
pulling the tube out.
If the patient refuses the tube,
they should have the risks
and consequences explained
to them so that they can make
an informed choice.
Doctor/specialist nurse to discuss the procedure,
pros and cons with the patient/relatives and
obtain consent.
Document consent in medical notes
Insert NG tube and check tube position as per
Trust guidelines prior to inserting the bridle as
per manufacturer’s guidelines
http://www.appliedmedical.net/bridleVideo/br
idleVideosWindow.htm
Monitor for complications. Refer to flow chart
to guide management if displacement of
nasal bridle/tube.
Refer to flow chart to guide
decision making making for
tube feeding route
Nasal bridle to proceed
Yes No

APPENDIX 2
Nasal Bridle Fixation Device Request Form
To be used alongside the NG care plan document. Please complete all the information requested on
this form. Fax the form to x1904, Gastroenterology Department.
Patient Details:
Name: ……………………………………………………… Hospital No:...........................
Date of Birth:…………………….. Ward.................................
Consultant...................................................................
Is the patient
NBM On NG Feed Eating orally
Date of last SALT review ............................ Date of last dietetic review.......................
Number of NGs pulled out by the patient?.................................
Can the patient consent to the bridle Yes/No
Has the bridle been discussed with the patient relatives (if appropriate) Yes/No
Is the patient receiving or has had recent anticoagulation therapy Yes/No
If the patient has any of the following conditions nasal bridle is not appropriate
Extreme confusion and likely to pull at the tube Yes/No
Known basal skull fractures Yes/No
Deviated or perforated nasal septum Yes/No
Structural deformity of the nose or nasopharynx Yes/No
Advanced dementia Yes/No
Recent radiotherapy to the nose or nasopharynx Yes/No
Bridle requested by (name/title)..................................................................................
Doctor’s signature................................................ Contact number.............................

APPENDIX 3. FLOW CHART TO GUIDE MANAGEMENT IF NASAL BRIDLE AND / OR NASOGASTRIC TUBE DISPLACED
*If there is a delay for specialist/trained intervention – continue with NG therapy and monitor carefully for unplanned tube removal. Bolus administration only
recommended.
**Refer to flow chart to guide decision making making for tube feeding route. back to index
NG still in
Bridle out
Review patient
condition and
reason for removal
Yes
Refer to specialist/HCP trained in the
procedure for reinsertion of bridle*
Check NG tube still in position prior to
reinsert bridle as per Trust
guidelines and secure to NG tube.
If NGT also pulled out, reinsert NG
tube and check position as per Trust
guidelines, then secure to bridle.
No
Remove bridle and continue with oral
diet.
Bridle and
NG out
NG still required**
Bridle still
required**
Reinsert NG tube as per Trust
guidelines and consider whether
bridle still required, if not, remove
bridle.
Remove NGT and continue with oral
diet.
NG still
required**
Yes
No
Review
patient
condition and
reason for
removal.
NB. There
may be
damage to
nasal septum
if bridle
removed
forcefully.
Bridle still
required**
Yes Reinsert NG tube and check position
as per Trust guidelines, then secure
to bridle.
Yes
No
NG out
Bridle still in
No
No
Yes No

APPENDIX 4 SUPPORTING INFORMATION back to index
NPSA alerts relating to Nasogastric feeding
Manufacturer’s websites
Applied Medical Technology (AMT ) nasal bridle
http://www.appliedmedical.net/amtbridle.htm
http://www.appliedmedical.net/bridleVideo/bridleVideosWindow.htm
Abbott Nutrition home page – access to pump instruction manuals and training
Videos
http://www.abbottnutritionuk.com/
Corpak Medsystems – access to information about enteral tubes and company guidelines
http://corpakmedsystemsuk.com/
Medicina – information about enteral syringes and feeding devices
http://www.medicina.co.uk/
back to index

END OF EAST CHESHIRE NHS TRUST CNSG 008 GUIDELINES
FOR INSERTION AND MANAGEMENT OF NASAL BRIDLES
back to index
back to main index

East Cheshire NHS Trust CNSG 009 Guidelines for Insertion and Management of Gastrostomy Tubes Page 38 of 172
Created by Maggie Allen. October 2010. Updated July 2015
Guideline Title: Guidelines for Insertion and Management of Gastrostomy Tubes.
Executive
Summary:
gastrostomy tube under the care of East Cheshire NHS Trust.
Description of
Amendment(s):
Guidelines reviewed - New guidance: -
Stop Clopidogrel 7 days prior to PEG insertion and to omit new
anticoagulants dependent on specific anticoagulant and patient’s renal
function.
Updated advice on optimum positioning of gastrostomy tube.
Version Number: 1.1 Effective Date: November 2010
GI Nurse Specialist
Impact Assessment
Date:
August 2014
APPROVAL RECORD
Committees / Group Date
Gastroenterology
Infection prevention and control
October 2010
June 2015
AMENDMENTS RECORD

Created by Maggie Allen October 2010. Updated July 2015.
GUIDELINES FOR INSERTION AND MANAGEMENT OF GASTROSTOMY TUBES
INDEX
1.0 Definition 41
2.0 Indications 41
3.1 Advanced dementia 42
4.0 Referral 43
5.0 Information giving and informed consent 43
5.1 Capacity and consent 43-4
5.2 Multidisciplinary team 44
6.0 Preparation and Assessment 45-7
6.1 Type of tube 47
7.0 Patient care post gastrostomy insertion 48
7.1 Peri and postoperative complications of PEG insertion 48
7.2 Monitoring 48
7.3 Commencing feed/oral diet 49
7.4 Mouth care 49
7.5 Pain control 49
7.6 Gastrostomy site care 50
7.6.1 Procedure to clean a gastrostomy site 50
7.6.2 Bathing and showering 51
7.6.3 Gastrostomy site dressings 51
7.6.4 Positioning the fixation device 51
7.6.5 Prevention of buried bumper syndrome 51
7.6.6 Sutures 52
8.0 Maintenance of the gastrostomy tube 52
8.1 Flushing 52
8.2 Syringes 52
8.3 General maintenance of the tube 52
9.0 Removal of a gastrostomy tube 53
9.1 Accidental removal 53
9.2 Planned removal 53
9.3 Procedure for traction removal of a Merck Corflo gastrostomy tube 53-4
10.0 Management of balloon gastrostomy tubes 54
10.1 Definition 54
10.2 Low profile gastrostomy tubes – buttons 54
10.3 General management of balloon gastrostomy tubes, buttons and
extension sets
54-5
10.3.1 Preparation of an extension set for administering fluids via a low
profile device
55
10.3.2 Cleaning an extension set after use and replacement 55
10.4 Checking the balloon volume 56
10.5 Removal of a balloon gastrostomy tube 57
10.6 Discontinuing balloon gastrostomy feeding 58
10.7 Replacement of a balloon gastrostomy tube 58
Back to main index

INDEX CONTINUED
10.8 Insertion procedure for a balloon gastrostomy tube 58-60
10.9 Insertion of a low profile device 60
10.10 Measurement of a gastrostomy stoma 60
10.11 Complications 60
10.12 Accidental removal of gastrostomy tube 61
10.13 Temporary gastrostomy tubes 62
10.14 Spare tubes 62
11.0 Management of an intestinal tube within a PEG tube for buried
bumper
63
11.1 Insertion/replacement of an intestinal tube within a PEG tube 63-4
11.2 Care of an intestinal tube within a PEG tube 64
12.0 Radiologically inserted gastrostomy tubes (RIG) 65
12.1 Referrals 65
12.1 Sutures 65
13.0 Discontinuation of tube feeding 65
14.0 Discharge of patients on enteral feeding 65-6
14.1 Discharge within 72 hours of PEG insertion 65
14.2 Information required for discharge within 72 hours of insertion 66
14.3 Training required prior to discharge 66
14.4 Information and contact details required prior to discharge 66
14.5 Referrals required prior to discharge 66
14.6 Equipment required for discharge 66
Appendix 1 References and bibliography 67
Appendix 2 Linked supporting documents: -
 Discharge check list
 NPSA alerts relating to PEG
 Manufacturer’s information
 Care Pathway for Percutaneous Endoscopic Gastrostomy
(PEG) Tubes
68
Back to main index

1.0 DEFINITION back to index
A gastrostomy tube is the generic term for a feeding tube that is inserted into the stomach either,
surgically, endoscopically (PEG) or radiologically (RIG). The gastrostomy tube allows delivery of
nutrients, fluid and medication directly into the stomach.
Percutaneous Endoscopic Gastrostomy (PEG) is the insertion of a small plastic tube through the
abdomen and into the stomach under endoscopic vision. The following guidelines are biased
towards this type of procedure as radiological insertion of a gastrostomy (RIG) is not currently
undertaken at the Trust.
2.0 INDICATIONS back to index
When selecting patients for gastrostomy/PEG insertion the following should be considered:
 Artificial nutrition is appropriate for the individual
 Patients require enteral nutritional and hydration support (partial or complete) for more than 6
weeks.
 The individual has a functional gastrointestinal tract.
 Nasogastric (NG) tube feeding has not been tolerated or is thought to be unsafe.
- The patient has pulled out the NG tube on at least 3 occasions in short succession and use
of a nasal bridle is contraindicated. Refer to CNSG 008 guidelines for management of
nasal bridles for further information.
- The patient demonstrates significant distress during NG insertion.
- The patient refuses nasogastric tube insertion.
- Altered anatomy e.g. large hiatus hernia, increasing the risk of aspiration.
- Basal skull fracture, as the tube may enter the brain if incorrectly positioned (oro-gastric
positioning may be appropriate).
- Obstructive pathology in oropharynx or oesophagus preventing passage of the tube e.g.
stricture, tumour.
 The patient is fit enough and will benefit from the procedure back to index
- Procedure related mortality 0.7-2%.
- 30-day mortality rate 2-28%
- Complications post PEG 15-70%
(NCEPOD 2004 and BSG Guidelines 2006)
http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/complicati
ons.pdf
http://www.ncepod.org.uk/2004report/index.htm
High risk groups include individuals with significant co-morbidity, in particular those with
aspiration pneumonia prior to PEG insertion. See section 6 below for further information.
 Tolerance of the gastrostomy tube by patient/partner.
- Physical implications – changes to body image, foreign object in body, feel unable
undertake activities such as swimming.
Psychological implications - changes to body image which may affect the individual and their
partner, unable to engage in normal social activity such as eating, regular interference with the
body by others accessing the gastrostomy tube to deliver feed and fluids.
back to index

3.0 CONTRAINDICATIONS back to index
Table 1
Absolute Relative
 Tense ascites
 Peritoneal dialysis
 Total gastric outflow obstruction
 Morbid obesity
 Treatment with high dose steroids
 Previous upper GI surgery
 Partial gastric outflow obstruction
 Advanced dementia (see below)
 Coagulopathy disease/drugs
 Gastro-oesophageal reflux with risk of
aspiration
 Recurrent aspiration pneumonia due to
severe dysphagia following a stoke
3.1 Advanced dementia back to index
The following summary illustrates the problems faced in deciding whether a gastrostomy tube is
appropriate for an individual with advanced dementia.
There is insufficient evidence to suggest that enteral tube feeding is beneficial in
patients with advanced dementia. Data are lacking on the adverse effects of this
intervention
Patients with advanced dementia often develop dysphagia (difficulties swallowing). They
also experience changes in appetite and apraxia (difficulty co-coordinating movements) and
may have difficulties feeding themselves. Two methods of enteral tube feeding are
commonly used: the administration of food and fluids via a nasogastric tube (a tube that is
passed through the nose and into the stomach) or via a percutaneous endoscopic
gastrostomy (PEG) where a feeding tube is inserted into the stomach and is accessed
through a permanent incision in the abdominal wall. The decision to use artificial hydration
and nutrition in someone with dementia is often emotive and complex. Relatives and carers
may request the intervention because they are concerned that the patient may starve;
clinicians may be aware of the risks but feel pressurised by institutional, societal or even
legal directives to intervene. We found no conclusive evidence that enteral tube nutrition is
effective in terms of prolonging survival, improving quality of life, or leading to better
nourishment or decreasing the risk of pressure sores. It may actually increase the risk of
developing pneumonia due to inhaling small quantities of the feed and even death. This
area is difficult to research but better designed studies are required to provide more robust
evidence
Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane
Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007209. DOI: 10.1002/14651858.CD007209.pub2
Further information and guidance regarding the difficulties in providing nutrition support can be
found in:
Oral feeding difficulties and dilemmas. A guide to practical care, particularly towards the end of life.
Report of a joint RCP/BSG Working Party - January 2010.
https://www.rcplondon.ac.uk/sites/default/files/documents/oral-feeding-difficulties-and-
dilemmas.pdf
back to index

4.0 REFERRAL back to index
The patient should be referred to: -
 Gastroenterologist/Specialist nurse
 Dietitian
 Speech and language therapists (where appropriate)
 Independent mental capacity advocate (IMCA)(If the patient lacks capacity to make an
informed decision and does not have any family or friends with whom it is ‘appropriate to
consult’ about the decision – see section 5 below for further information)
5.0 INFORMATION GIVING AND INFORMED CONSENT back to index
Decision-making and consent may be affected by previous experiences and/or by fear. Time
should be spent explaining about gastrostomy feeding to the individual and family. They may find it
useful to meet someone else with a gastrostomy tube. Information about support groups should
also be offered.
Key information to be discussed includes: -
 Full explanation of the procedure and associated complications (see section 7.1 below).
Written information should also be offered (EIDO E09 PEG leaflet, accessible from the Trust
front page. Click on Patient information, then EIDO link and log in following instructions. Once
logged in, scroll down to Endoscopy and click on PEG, print off as required.
 Benefits and disadvantages of gastrostomy feeding
 Aftercare
 Major impact on lifestyle, for instance if alternative accommodation needs to be considered if
the patient needs specialist care post gastrostomy.
The patient’s consent should be written where possible on the Trust consent form (Form 1). If this
is not possible, verbal consent should be witnessed on the Trust consent form (Form 1). Refer to
East Cheshire NHS Trust consent policy for further information regarding the validity of consent. If
communication is impaired, every effort should be made to communicate with the individual,
including the use of drawings/props where necessary. In some cases repeated sessions to impart
information may be necessary. Evidence of these conversations should be documented in the
patient’s notes. Liaison with other healthcare professional e.g. speech and language therapists
(SALT) may be indicated to maximise communication techniques.
5.1 Capacity and consent back to index
Assessment of capacity to make informed decisions should be made prior to PEG insertion. If the
individual is thought not to have capacity for informed consent, it is important to have early,
sensitive discussions with relatives or individuals close to the patient, to try to determine whether
the individual has previously expressed any views on the subject, or if they have a legitimate
advanced decision, or have appointed a lasting power of attorney to make decisions for them, as
legislated for within the Mental Capacity Act (MCA) 2005. In absence of a valid advanced decision
or lasting power of attorney (welfare), the family should be reassured that the decision making is
not their responsibility, but that of the clinician (Decision Maker) in charge of their relatives care, to
make the decision regarding PEG based on the individual’s best interests. Under these
circumstances an additional safeguard has been implemented by the Act which requires clinicians
to involve an independent mental capacity advocate (IMCA) for serious medical treatment
decisions when: -
 a best interests decision is required because the doctor has assessed the person as not
having the capacity to make the decision themselves.
 the person does not have family or friends with whom it is ‘appropriate to consult’ about the
decision.

Serious medical treatment is defined in the Mental Capacity Act 2005 (Independent Mental
Capacity Advocates) (General) Regulations 2006 as treatment which involves providing,
withdrawing or withholding treatment in circumstances where one or more of the following apply:
 in a case where a single treatment is being proposed, there is a fine balance between its
benefits to the patient and the burdens and risks it is likely to entail for them
 in a case where there is a choice of treatments, a decision as to which one to use is finely
balanced
 what is proposed would be likely to involve serious consequences for the patient.
The MCA Code of Practice states that ‘serious consequences’ may include treatment options
which:
 cause serious and prolonged pain, distress or side effects
 have potentially major consequences for the patient (for example, major surgery or
stopping life-sustaining treatment)
 have a serious impact on the patient’s future life choices. back to index
Patients who have been referred for PEG and lack capacity for decision making and do not have
any family or friends with whom it is ‘appropriate to consult’ about the decision, should be referred
to an IMCA as they fall within several of the above criteria. The IMCA ensures that the Decision
Maker (clinician) considers what the wishes and beliefs of that person would be when deciding
what course of action to take. This is done by questioning all the people involved with that person,
investigating the medical condition and treatment options and making recommendations based on
these findings. This statutory IMCA service is provided by qualified Independent Mental Capacity
Advocates.
For further information please contact East Cheshire Advocacy on:
Tel. 01625 534889
Online. www.ecadvocacy.co.uk
Email: admin@ecadvocacy.co.uk
East Cheshire Advocacy, 81 Park Lane, Macclesfield, SK11 6TX.
If an individual is assessed as lacking capacity to give informed consent, the ‘Form for adults who
are unable to consent to investigation or treatment’ (Consent Form Four) should be completed.
The form should be signed by the clinician in charge of care, the clinician undertaking the
procedure and the patient’s family/carers to indicate that they have been involved in the discussion
process. If the family are unable to sign the form, there should be documented evidence in the
patient’s medical notes regarding the discussion process.
5.2 Multidisciplinary team (MDT) approach back to index
For patients who lack capacity to make an informed choice, there are potentially difficult ethical
decisions to be made. Each patient considered for PEG feeding should be assessed on his or her
own merits. They may not fall within the above criteria. The decision should be made within an
MDT approach and based on the patient’s best interests. The team should consist of healthcare
professionals involved with the patient, e.g. speech and language therapist, dietitian, doctor
(including GP if appropriate), nurse (ward level and specialist), physiotherapist, occupational
therapist, social worker, community carers. Where the situation is particularly complex, or the MDT
decision is equivocal, consider referral to the palliative care consultant.

6.0 PREPARATION AND ASSESSMENT PRIOR TO PEG back to index
Clinical assessment
In addition to assessing for contraindications, the following should be considered: -
Table 2
CONDITION RATIONALE
Relevant co-morbidity Increases risk of complications during or post
PEG insertion.
Infection prior to PEG Increases risk of complications during or post
PEG insertion.
If patient is MRSA positive –follow MRSA Trust
policy. In relation to antibiotics/treatment refer to
Trust antibiotic policy, contact the IPCT and/or
the Microbiologist.
Cervical/Neck problems May affect positioning during PEG insertion.
Tracheostomy Requires specialist support and suctioning
during the procedure.
Previous abdominal surgery Altered anatomy and adhesion increases the
risk of bowel perforation.
Respiratory condition Known aspiration pneumonia or respiratory
problems prior to the procedure carries an
increased risk of fatality post procedure. Local
audit 2001-2004 indicated that 66% of patients
diagnosed with aspiration pneumonia prior to
PEG insertion, died within 30 days of the
procedure.
Allergies Ensure the patient is prepared safely for the
procedure.
Unable to open mouth/ poor dentition Increased risk of damage to teeth during
endoscopy. Poor dentition will increase the
amount of bacteria in the mouth which if
aspirated will result in an increased risk of
respiratory infection. Referral to a dentist may
be required.
Coagulopathy
PEG is contra-indicated if INR >1.3
Severely malnourished patients may have a
vitamin K deficiency which will need correcting
prior to PEG.
Anticoagulant therapy
PEG is contra-indicated if INR >1.3
Anticoagulants need to be stopped prior to PEG
See below.
Severely malnourished - risk of re-feeding
syndrome
Increased risk of electrolyte imbalance once
feeding starts.
Thrombocytopenia
PEG is contra-indicated if platelet count <100
Low platelet count causes increased risk of peri-
procedural bleeding.
back to index

6.0 PREPARATION continued back to index
Preparation Action
Bloods FBC If platelet count <100 consider correcting with 1 -2 units of
platelets within 4 hours of the procedure.
INR If INR > 1.3: Correct and recheck
U& Es inc calcium
group, phosphate
and magnesium and
levels
Correct any electrolyte disturbances before commencing
nutritional support. Re-feeding drugs, if required, should be
prescribed according to CNSG Guidelines for Re-feeding
management.
Review
medication
Anticoagulants PEG is classified as a high risk procedure with regards to
risk of bleeding and anticoagulation therapy.
NB. Some anticoagulants need stopping up to 7 days
prior to PEG e.g Clopidogrel 7 days, Warfarin 5 days.
New anticoagulants - the stoppage time will depend on
the particular anticoagulant and the patient’s renal
function. Alternative anticoagulation therapy may be
required depending on the patient’s medical condition.
Check with gastroenterology/haematology team for further
advice.
Current drug therapy Refer to pharmacist as the patient’s drug formulations may
need to be changed. Timing and dosage of drug
administration may need to be altered due to altered drug
formulation and/or potential interaction with feed, particularly
in the drug has a narrow therapeutic index. Refer to CNSG
016 Guidelines for Administration of Medication via
Enteral Feeding Tubes.
Medication
required
Prophylactic
antibiotics
Patients should have a single dose of intravenous Co-
amoxiclav 1.2g, just before the procedure.
British Society of Gastroenterology (BSG) 2009. Antibiotic
prophylaxis in gastrointestinal endoscopy.
If penicillin allergic, give a single dose of Gentamicin 3mg/kg
(max 300mg), just before the procedure (maximum of 1
hour). If MRSA discuss with microbiologist.
MRSA eradication
therapy (if known
MRSA colonisation
or infection)
 If the patient is MRSA positive contact the
IPCT/Microbiologist for advice regarding suppression
therapy prior to insertion (as per Trust MRSA policy).
 If antibiotics are required, they should be prescribed as
per Trust antibiotic policy.
Analgesia Prescribe prn soluble oral and IM analgesia for pain post
PEG insertion (arrange for a take home prescription if for
discharge post PEG).
Feed Doctor/dietitian to write up feed on prescription chart and
feeding regimen.
Corsodyl mouthwash
(chlorhexidine
gluconate 0.2%)
To start 48 hours prior to procedure. Aim to reduce bacterial
load in mouth, as the tube is pulled though the mouth and
into the newly formed stoma.
back to index

6.0 PREPARATION continued back to index
Preparation Action
Weight A baseline and regular weight is required in order to: -
 accurately assess nutritional and fluid requirements
 assess weight following PEG insertion (barometer of the patient’s
nutritional requirements and monitors for potential fluid overload).
Fasting Fasting (mouth and tube) 6 hours prior to procedure.
Hygiene  Full wash
 Clean theatre gown
 Clean sheets.
Venous access Must be established before the patient arrives on the Endoscopy Unit
(except for outpatients).
Mouth Care  Regular mouth care required with Corsodyl mouthwash - to reduce
risk of stoma infection. The mouth must be clear of dried secretions
prior to PEG insertion. There is an increased risk of stoma infection if
the mouth is not clean at the time of PEG insertion. If mouth care is
difficult, inform specialist nurse.
 Advise endoscopy staff of loose/broken teeth.
Equipment
required
Pump, giving sets, oral/enteral syringes, recommended feed, sterile water
for first flush, tap water for subsequent flushes.
Subcutaneous
fluids
Avoid siting the butterfly cannula in the upper central abdomen as this can
result in skin infections or abscesses that may affect PEG insertion.
(Insertion of sub cut cannula must be done using aseptic technique).
Documentation
required
The following
documents must be
sent with the patient
to the endoscopy
unit at the time of
the procedure:
 Signed consent form
 Patient notes
 Nursing Kardex
 Drug charts
 Completed PEG pathway (Click for link)
6.1 Type of tube back to index
The tube of choice at East Cheshire NHS Trust is a Merck Corflo traction removable tube. It is
available in 12Fr, 16Fr and 20Fr sizes. Most patients have a 16Fr tube inserted. Other sizes may
be used depending on the patient’s requirements. The most appropriate type of tube and size will
be decided at the time of assessment. Greater than 16Fr tubes should be avoided due to
increased risk of stoma leakage.

7.0 PATIENT CARE POST PEG INSERTION back to index
7.1 PERI AND POST PROCEDURAL COMPLICATIONS ASSOCIATED WITH PEG
 Perforation
 Haemorrhage
 Sepsis
 Peritonitis
 Respiratory depression due to sedation
 Pulmonary aspiration
 Peristomal site infection
 Ischaemic pressure necrosis
 Gastrocolic fistulae
 Tube blockage
 Accidental displacement of the PEG
Monitor patient post PEG for development of complications and report promptly.
Link to management of suspected peritonitis
Link to flow chart for complications post PEG and management
7.2 MONITORING back to index
Observations
 Half hourly for a minimum of 2 hours.
o Blood pressure, pulse and temperature
o Oxygen saturation and respiratory rate
o Wound check
o Pain assessment
o PEG position unchanged
 Hourly for a minimum of 2 hours.
o As per half hourly assessments
 2 - 4 hourly (depending on clinical status).
o As per half hourly assessments
Discontinue as clinical condition allows
Bloods
 Repeat full profile if at risk of re-feeding syndrome. See CNSG re-feeding guidelines or contact
the dietitian.
 Repeat U& Es. Refer to CNSG Guidelines for Assessment and Monitoring for further guidance.
Contact dietitian for information.
back to index
Bowels
 Document and monitor bowel movements
 Consider aperients if constipated
NB. Constipation presents serious hazard for a patient following PEG insertion. A build up of
pressure within the abdomen may increase the risk of leakage from the stomach into the peritoneal
cavity with subsequent peritonitis. There is also an increased risk of vomiting which places the
patient at greater risk of aspiration, particularly if they have an unsafe swallow.
Weight
As requested by dietitian. back to index

Nutrition management of enteral feeding - guidelines and procedures ect2353

Nutrition management of enteral feeding - guidelines and procedures ect2353

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