meddy05
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Hi I am on my assistantship at the moment.

I encountered a patient today and had inserted an NG tube under supervision. We failed aspiration and requested CXR. A doctor 2 hours later managed to get an aspirate and it was <5.0 but the CXR came back where the tube had bisected carina fine but was not below diaphragm. He though it was at GOJ and said not to use.

In this case then would we ignore what the aspirate suggests?

I'm asking here as wasn't able to get an answer today and the assistantship has now finished haha.

Thank you
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meddy05
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Chief Wiggum
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(Original post by meddy05)
Hi I am on my assistantship at the moment.

I encountered a patient today and had inserted an NG tube under supervision. We failed aspiration and requested CXR. A doctor 2 hours later managed to get an aspirate and it was <5.0 but the CXR came back where the tube had bisected carina fine but was not below diaphragm. He though it was at GOJ and said not to use.

In this case then would we ignore what the aspirate suggests?

I'm asking here as wasn't able to get an answer today and the assistantship has now finished haha.

Thank you
Yes, I would go with the CXR, and advance the tube further, then re-image.
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meddy05
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(Original post by Chief Wiggum)
Yes, I would go with the CXR, and advance the tube further, then re-image.
Ahh okay it was just that he had alot of pushback from nurses about it the aspirate being well below 5 and if we hadn't done CXR we would have used it lol.
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Chief Wiggum
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(Original post by meddy05)
Ahh okay it was just that he had alot of pushback from nurses about it the aspirate being well below 5 and if we hadn't done CXR we would have used it lol.
You mean the nurses were keen to just go ahead and use it? That's odd, usually nurses would err on the side of caution.

Tbh, I would always request a CXR post NG insertion, regardless of aspirate.
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meddy05
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(Original post by Chief Wiggum)
You mean the nurses were keen to just go ahead and use it? That's odd, usually nurses would err on the side of caution.

Tbh, I would always request a CXR post NG insertion, regardless of aspirate.
Yeah they were keen to get the feed as the patient hadn't eaten for 12 days and okay I asked the doctors and they said they don't always get a CXR post-insertion if the aspirate is okay. But guess its down to the individual.
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ForestCat
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There are been plenty of never events where people have been fed into the lungs and it would be the doctors who get hung for it. Some trusts I’ve worked in require radiologists to confirm placement prior to feeding.

I agree it’s odd for the nurses not to be treading on the cautious side. My argument would be if they haven’t fed for 12 days a few hours won’t hurt as they’ll be on a very strict (likely low volume) refeeding plan. And that delay is far better than a massive pneumonia from feeding them unsafely. I would also remind them that a ph isn’t fool proof.
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Democracy
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(Original post by meddy05)
Ahh okay it was just that he had alot of pushback from nurses about it the aspirate being well below 5 and if we hadn't done CXR we would have used it lol.
It's his registration on the line not theirs - clearly he realised that. Although as the others have said, it's somewhat surprising the nurses were being so cavalier about it.
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meddy05
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(Original post by ForestCat)
I agree it’s odd for the nurses not to be treading on the cautious side. My argument would be if they haven’t fed for 12 days a few hours won’t hurt as they’ll be on a very strict (likely low volume) refeeding plan. And that delay is far better than a massive pneumonia from feeding them unsafely. I would also remind them that a ph isn’t fool proof.
Yeah I can understand this. Just that in this trust they declare NGs safe to use if initial aspirate suggests its sited - a doctor also said this and many have declared so. Just felt like a tit when I said isn't the CXR necessary after all NGs and was met with a bit of "hmph". But after seeing the CXR where the NG was above diaphragm I felt there is also the risk of aspiration rather than simple misplacement. Anyways, think I'm always just going to get the CXR as the above poster had said, regardless of aspirate.

Thanks guys.
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fishfacesimpson
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(Original post by ForestCat)
There are been plenty of never events where people have been fed into the lungs and it would be the doctors who get hung for it. Some trusts I’ve worked in require radiologists to confirm placement prior to feeding.

I agree it’s odd for the nurses not to be treading on the cautious side. My argument would be if they haven’t fed for 12 days a few hours won’t hurt as they’ll be on a very strict (likely low volume) refeeding plan. And that delay is far better than a massive pneumonia from feeding them unsafely. I would also remind them that a ph isn’t fool proof.
I haven't worked in a trust for a few years now (in England) where NG cxr are not reported by radiologists
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nexttime
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(Original post by meddy05)
Hi I am on my assistantship at the moment.

I encountered a patient today and had inserted an NG tube under supervision. We failed aspiration and requested CXR. A doctor 2 hours later managed to get an aspirate and it was <5.0 but the CXR came back where the tube had bisected carina fine but was not below diaphragm. He though it was at GOJ and said not to use.

In this case then would we ignore what the aspirate suggests?

I'm asking here as wasn't able to get an answer today and the assistantship has now finished haha.

Thank you
CXR trumps pH always.
(Original post by meddy05)
Ahh okay it was just that he had alot of pushback from nurses about it the aspirate being well below 5 and if we hadn't done CXR we would have used it lol.
As stated, its your registration on the line, not theirs. Whilst listening to experienced nurses is great advice for new doctors, they are still nurses with no medical training!
(Original post by Chief Wiggum)
You mean the nurses were keen to just go ahead and use it? That's odd, usually nurses would err on the side of caution.

Tbh, I would always request a CXR post NG insertion, regardless of aspirate.
(Original post by meddy05)
Yeah they were keen to get the feed as the patient hadn't eaten for 12 days and okay I asked the doctors and they said they don't always get a CXR post-insertion if the aspirate is okay. But guess its down to the individual.
Pretty sure there are multiple national guidelines that say a CXR is mandatory and it has been that way for some years e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC549648/

Not doing so would be pretty rogue at this point! I personally would not just dismiss it as 'down to the individual'. As stated above, many trusts insist on not only a CXR, but you phoning a radiologist to report if for you.
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Chief Wiggum
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(Original post by nexttime)
CXR trumps pH always.

As stated, its your registration on the line, not theirs. Whilst listening to experienced nurses is great advice for new doctors, they are still nurses with no medical training!


Pretty sure there are multiple national guidelines that say a CXR is mandatory and it has been that way for some years e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC549648/

Not doing so would be pretty rogue at this point! I personally would not just dismiss it as 'down to the individual'. As stated above, many trusts insist on not only a CXR, but you phoning a radiologist to report if for you.
That link is from 2005, and doesn't say a CXR is mandatory.

"It issued a list of recommended tests including measuring the acidity/alkalinity of aspirate (stomach contents) using pH indicator strips in the range 0 to 6 with half point gradations; testing the aspirate should not be done with blue litmus paper.

Radiography is recommended for intensive care patients or neonates but should not be used routinely."


That seems pretty out of date though. I would always do a chest x-ray. I think that's common practice now.
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Starz678
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(Original post by meddy05)
Hi I am on my assistantship at the moment.

I encountered a patient today and had inserted an NG tube under supervision. We failed aspiration and requested CXR. A doctor 2 hours later managed to get an aspirate and it was <5.0 but the CXR came back where the tube had bisected carina fine but was not below diaphragm. He though it was at GOJ and said not to use.

In this case then would we ignore what the aspirate suggests?

I'm asking here as wasn't able to get an answer today and the assistantship has now finished haha.

Thank you
In the trust I’m currently at, pH is first line for NG placement. Nurses mostly insert all NG’s , they would only ask the doctors to get a CXR if they can’t get an aspirate.

If I personally insert an NG (a rare event now) then I always get a CXR but I see the nurses do them all the time and commence feed if the pH is ok 🤷🏼*♀️🤷🏼*♀️
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nexttime
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(Original post by Chief Wiggum)
That link is from 2005, and doesn't say a CXR is mandatory.

"It issued a list of recommended tests including measuring the acidity/alkalinity of aspirate (stomach contents) using pH indicator strips in the range 0 to 6 with half point gradations; testing the aspirate should not be done with blue litmus paper.

Radiography is recommended for intensive care patients or neonates but should not be used routinely."


That seems pretty out of date though. I would always do a chest x-ray. I think that's common practice now.
Oops It was a very quick search!

I'm sure they do exist though.
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Jckc123
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in my trust now, we cant request an X-ray if we get a pH<5.0. (it will get rejected).
so we cant always request an X-ray post NG if we get an aspirate (unless the pH is high of course)

havent been in a situation whereby ill need to request a CXR when i get an aspirate. so will be interesting to see when i do request one if im not satisfied with the placement even with an aspirate.
i usually further justify the placement by doing the 'whoosh' test (dont use this to confirm placement though)
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