INTRODUCTION

When a person is unable to take or eat food by mouth the physician may choose
another method of feeding i.e. gastric gavage. The word gavage comes from the
French gaver meaning to gorge fowls. Gastric gavage is an artificial method of
giving fluids and nutrients through a tube that has passed into stomach through
the nose, mouth or through the opening made on the abdominal wall. It has a
number of advantages over parenteral nutrition. It helps in maintaining GI
structure and motility that help in discouraging bacterial over growth.

 Gastric lavage is a gastrointestinal decontamination technique that aims

to empty the stomach of toxic substances by the sequential
administration and aspiration of small volumes of fluid via an orogastric
tube.

 previously widely favoured method that has now been all but abandoned
due to lack of evidence of efficacy and risk of complications.

RALATED ANATOMY AND PHYSIOLOGY

The digestive canal is composed of the mouth, oesophagus, stomach, a small
intestine and large intestine. In mouth there are tongue, teeth and salivary
glands. From the mouth the food goes to the oesophagus and then to the
stomach. Food remains in the stomach for 1-4 hours. Chemical changes take
place in food due to gastric juices. The pyloric sphincter allows the passage of
food into the small intestine. The small intestine has three parts- duodenum,
jejunum, and ileum. The accessory organs of digestion are- three pairs of
salivary glands, pancreas, liver and biliary tract.

DEFINATION
- It is an artificial method of giving fluids and nutrients through a
tube that has been passed into the stomach and oesophagus through
the nose, mouth or through an opening made on the abdominal wall

PURPOSES:
  To introduce liquid food into the stomach in order to meet nutritional
needs
 To give large number of fluids safely
 To prevent the danger of parenteral feeding. e.g. Infection, thrombosis.

INDICATIONS

Gastric lavage should be rarely, if ever, performed.

 The amount of toxin removed by gastric lavage is unreliable and often

negligible, especially if performed after the first hour.

 There are few (if any) situations where the expected benefits of gastric
lavage would exceed the risks involved and where administration of
activated charcoal would not be providing equal or greater efficacy of
decontamination.

TYPES OF GASRIC GAVAGE

Based on route of insertion and method of administration:

ROUTE OF INSERTION:

 NASOGASTRIC TUBE FEEDING

 ORO-GASTRIC FEEDING
 GASTROSTOMY TUBE FEEDING

METHODS OF ADMINISTRATION CONTINUOUS FEEDING

METHOD

1. By continuous drip method

2. By syringe and infusion pump method.

INTERMITENT FEEDING METHODBOLUS FEEDING METHOD

TYPES OF NASOGASTRIC TUBES

 The Levin Tube

 The Salem-Sump Tube
 The Miller-Abbott Tube
 The Cantor Tube

CONTRAINDICATIONS
 Initial resuscitation incomplete

 Risk assessment indicates good outcome with supportive care and

antidote therapy alone

 Unprotected airway where there is a decreased level of consciousness or

risk assessment indicates potential for these complications during the
procedure

 Small children

 Corrosive ingestion

 Hydrocarbon ingestion

TECHNIQUE
 Perform in an appropriately staffed and equipped resuscitation area

 Do not perform in any patient with an impaired level of consciousness

unless the airway is protected by a cuffed endotracheal tube

 Position the patient in the left decubitus position with 20° head down

 Measure the length of tube required to reach the stomach externally

before beginning the procedure
  Pass a large bore 36-40 G lubricated lavage tube extremely gently down
the oesophagus. Stop if any resistance occurs

 Confirm tube position by aspirating gastric contents and auscultating for

insufflated air at the stomach; consider CXR for confirmation of position

 Administer a 200 mL aliquot of warm tap water or normal saline into the
stomach via the funnel and lavage tube

 Drain the administered fluid into a dependent bucket held adjacent to the
bed

 Repeat administration and drainage of fluid aliquots until the effluent is

clear

 Activated charcoal 50 g may be administered via the tube once lavage

complete.

GENERAL INSTRUCTIONS

 Screen the patient for privacy

 Given only by the doctor’s order
 Explain the procedure and reassure him to win his confidence and co-
operation

REQUIREMENT
1. Nasogastric insertion equipments.
2. Lavage fluid – Nacl or other prescribed solution.
3. Syringe 20ml for aspiration and 50ml for lavage.
4. Specimen container with lab request form.
5. Kidney dish as receiver.
6. Measuring jug.
7. Protective sheet.
8. Clinical waste.
9. Domestic waste.

STEPS
 1. Verify Dr’s order.
2. Assets patient level of consciousness.
3. Greet patient and explain procedure.
4. Provide privacy.
5. Remove dental appliances and inspect oral cavity for loose teeth.
6. Position patient in Semi-Fowler’s.
7. Insert NG tube as per procedure handout.
8. Check placement of tube in stomach (3 times check).
9. Aspirate stomach contents before instilling water or antidote. Keep
specimen in container for analysis.
10.Remove 20ml syringe and attach with 50ml syringe to pour lavage
solution into NG tube or attach with 50ml syringe barrel.
11.Pour or inject slowly 20ml solution and wait for 1 minute.
12.Aspirate (if use syringe) or siphon (if use barrel) gastric contents and
discard it in kidney dish.
13.Save samples of first two washings.
14.Record input and output throughout procedures.
15.Repeat step 10-14 until returns are clear. Usually requires a total volume
of 2 Liters.
16.Remove NG tube as per procedure handout.
17.Make patient comfortable.
18.Label specimens and despatch to lab immediately.
19.Clean and clear equipments.
20.Record and report findings.

NURSING RESPONSIBILITY
1. Ensure procedure is carried out on correct client at correct site.
2. Assess patient’s level of consciousness.
3. Ensure patient’s comfort is maintained throughout procedure.

FOWLER’S POSITION.
1. Perform procedure in a correct manner. Use appropriate solution.
2. Monitor vital sign for pre, intra and post procedure.
3. Monitor input and output.
4. Send labelled specimens in appropriate container with lab request form.
5. Record and report findings.
AFTER CARE:
 Document the relevant information.
 Establish a plan for NG care.
 Inspect the nostril for discharge and irritation
 Clean the nostril and tube with moistened, cotton-tipped applicators.

COMPLICATIONS
 Incomplete decontamination leading to severe intoxication despite the
procedure

 Pulmonary aspiration

 Hypoxia

 Laryngospasm

 Mechanical injury to the gastrointestinal tract

 Water intoxication (especially in children)

 Hypothermia

 Distraction of staff from resuscitation and supportive care priorities

EVIDENCE
 most studies are low quality or methodological flawed

 no published data suggests that gastric lavage forces poison into the small
bowel

 animal and volunteer studies suggest variable and incomplete return of

ingested agents following gastric lavage (generally <50%), even after 15
minutes with rapid decline at 1 hour

 various case reports suggest recovery of ingested tablets with gastric

lavage, especially in situations where gastric emptying may be delayed
(e.g. hypothermia, anticholinergic syndrome), but there is no evidence
that this changes outcome
  no trials have shown benefit of gastric lavage over activated charcoal,
except for the subset of obtruded patients at >1hour in one
methodologically flawed study (Kulig et al, 1985)

HISTORICAL PERSPECTIVE
 Gastric lavage was first described in 1822 in London: Jukes’ “exhausting
pump” and Bush’s “gastric exhauster”, primarily used for opium
ingestion

 The heyday was in the 1950s and 1960s when gastric lavage was the
method of choice for all but first aid settings, and for almost all
significant poisonings. At this time barbiturate poisoning was rife and
most objective studies took place in this context

 Paediatricians led the way in turning from gastric lavage, due to inherent
difficulties in performing the procedure on children

 Position statements from the AACT and their European counterparts in

1994, 2003 and 2013 have, in essence, recommended that procedure be
abandoned

 The procedure is still widely performed in developing countries,

including India and Sri Lanka, partly because case fatality rates are
higher (10-20% versus 0.5% in the West), other therapeutic options may
be unavailable and because of entrenched dogma

THE ARGUMENT FOR GASTRIC LAVAGE

Some experts argue that there is still a role for gastric lavage if the following
criteria are met:

 staff are familiar with the procedure

 the patient is likely to die despite other therapies

 drug is still in the stomach (i.e. very early after ingestion)

 tablets will fit up a tube

 airway is protected (i.e. intubated)

However, such a situated is vanishingly rare (e.g. massive colchicine overdose)
and would likely require the intubation of asymptomatic patients almost
immediately after ingestion.

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