Insertion of a gastric tube through the mouth algorithm. Probing of the gastrointestinal tract: probing the stomach through the nose

Target

ü Medical.

ü Diagnostic (gastric lavage is used for stomach diseases, mainly for cytological examination rinsing waters, as well as for identifying poison in case of poisoning and for isolating the pathogen in case of bronchopulmonary inflammation (in case of ingestion of sputum by the patient) and various infectious lesions of the stomach).

Indications

ü Acute poisoning by various poisons taken orally, food poisoning, gastritis with abundant mucus formation, less often - uremia (with significant release of nitrogen-containing compounds through the gastric mucosa), etc.

ü The need to evacuate gastric contents in order to reduce pressure on the walls of the stomach and reduce the severity of nausea and vomiting associated with intestinal obstruction or surgery.

Contraindications to gastric lavage using the tube method

ü Large diverticula

ü Significant narrowing of the esophagus

ü Long-term periods (more than 6-8 h) after severe poisoning with strong acids and alkalis (possible perforation of the esophageal wall)

ü Ulcers of the stomach and duodenum.

ü Stomach tumors.

ü Bleeding from the upper gastrointestinal tract.

ü Bronchial asthma.

ü Severe heart disease.

Relative contraindications:

ü acute heart attack myocardium,

ü acute phase of stroke,

ü epilepsy with frequent convulsive seizures (due to the possibility of biting the probe).

Equipment

A thick gastric tube and funnel are usually used to lavage the stomach. Washing is carried out according to the siphon principle, when liquid moves through a liquid-filled tube connecting two vessels into a vessel located below. One vessel is a funnel with water, the other is a stomach. When the funnel rises, the liquid enters the stomach, and when lowered, it flows from the stomach into the funnel (Fig. 1).

· - Gastric lavage system: 2 thick sterile gastric probes connected by a glass tube (the blind end of one probe is cut off). You can also use a thin probe for these purposes.

· - Glass funnel with a capacity of 0.5-1 liters.

· - Towel.

· - Napkins.

· - Sterile container for collecting rinsing water for testing.

• - A container with water at room temperature (10 l).
• - Jug.
• - Container for draining wash water.
• - Gloves.
• - Waterproof apron.
• - Distilled water (saline solution).

Probe length measurement Rice. 2.

There are several ways to measure probe length.

ü It is necessary to measure the patient’s distance from the xiphoid process of the sternum to the ear and from the ear to the nose (Fig. 2).

ü You can subtract 100 cm from the patient’s height.

ü You can measure the patient’s distance from the incisors to the esophagogastric junction during endoscopy. A mark must be applied to the probe, to which it is wound up.

Patient position

ü Sitting on a chair, leaning firmly against its back, slightly tilting your head forward and spreading your knees so that you can place a bucket or basin between your legs.

ü If the patient cannot take this position, then the procedure is performed with the patient lying on his side.

ü Patients who are in comatose, gastric lavage is performed while lying on the stomach.

Administration technique gastric tube

It is more convenient for the person performing the procedure to stand to the right of the patient. (photo) Before starting the procedure, the patient must be put on an oilcloth apron; If he has removable dentures, they must be removed. In case of poisoning with cauterizing poisons (except phosphorus-containing ones), it is advisable to offer the patient to drink 50 ml before washing the stomach vegetable oil. Invite the patient to open his mouth. With your right hand, insert a thick gastric tube moistened with water to the root of the tongue. Place the blind end of the probe on the root of the tongue. Ask the patient to make several swallowing movements, during which you carefully advance the probe into the esophagus. You can suggest drinking water slowly. During swallowing, the epiglottis closes the entrance to the trachea, while simultaneously opening the entrance to the esophagus. The probe should be advanced slowly and evenly. If you feel resistance when inserting the probe, you should stop and remove the probe. Resistance when inserting a probe, cough, change in voice, vomiting, cyanosis, etc. indicate an erroneous entry of the probe into the trachea. Then the probe must be removed and the insertion procedure repeated from the beginning. If there is no resistance, then you can continue inserting the probe to the desired mark.

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Organ diseases abdominal cavity in many respects are the main subject of general surgery. The surgeon must have comprehensive knowledge of anatomy and skill in examining the abdomen. Manipulations of the gastrointestinal tract (GIT) should equally be an integral part of the surgeon’s technical equipment.

The purpose of gastrointestinal probing is to remove from the stomach (less often from more distal sections Gastrointestinal tract) gases and liquids for diagnostic and/or therapeutic purposes, as well as delivery of nutrients or drugs to the gastrointestinal tract.

Probing of the gastrointestinal tract has a rich history, and modern probes are the result of many years of modifications in materials and designs.

1. Indications:
a. Acute gastric dilatation
b. Pyloric obstruction
c. Intestinal obstruction
d. Small bowel obstruction
e. Upper gastrointestinal bleeding
f. Enteral nutrition

2. Contraindications:
a. Recent surgery on the esophagus or stomach
b. Lack of gag reflex

3. Anesthesia:
Not required

4. Equipment:
a. Levin probe or Salem drainage probe
b. Tray of crushed ice
c. Water-soluble lubricant
d. Syringe 60 ml with catheter tip
e. Cup of water with straw
f. Stethoscope

5. Position:
Sitting or lying on your back

6. Technique:
a. Measure the length of the probe from the lips to the earlobe and down the front abdominal wall so that the last hole on the probe is below the xiphoid process. This corresponds to the distance over which the probe must be inserted.
b. Place the tip of the probe in a tray of ice to stiffen it.
c. Apply lubricant to the probe generously.
d. Ask the patient to tilt his head and carefully insert the probe into the nostril (Fig. 4.1.).

Fig.4.1

e. Advance the probe into the pharynx along back wall, asking the patient to swallow if possible.
f. Immediately after the tube is swallowed, ensure that the patient can speak clearly and breathe freely, and then gently advance the tube to the marked length. If the patient is able to swallow, have him or her drink water through a straw; As the patient swallows, gently advance the probe.

G. Ensure proper placement of the tube in the stomach by injecting approximately 20 mL of air using a catheter-tipped syringe while listening to the epigastric region. The release of a large volume of fluid through the tube also confirms the location of the latter in the stomach.
h. Carefully tape the probe to the patient's nose, making sure that the probe does not press on the nostril. The probe must be kept lubricated at all times to prevent injury to the nostril. Using a patch and a safety pin, the probe can be attached to the patient's clothing.

I. Irrigate the tube every 4 hours with 15 ml of isotonic saline solution. To maintain proper functioning of the Salem drainage tube, inject 15 ml of air through the outflow (blue) port every 4 hours.
j. Continuous slow suction can be used with Salem drainage tubes, whereas Levin tubes should only be used for intermittent suctioning of gastric contents.
j. Check the pH of the Stomach every 4-6 hours and adjust it with antacids when the pH is<4.5.
l. Monitor gastric contents if a tube is used for enteral feeding. Use a chest x-ray to ensure the correct position of any tube before using it for enteral feeding.

7. Complications and their elimination:
a. Pharyngeal discomfort
. Usually associated with a larger probe gauge.
. Swallow tablets or small sips of water or ice may provide relief.
. Avoid the use of pharyngeal anesthesia aerosols as they may suppress the gag reflex and thus eliminate the airway defense mechanism.

B. Damage to the nostril
. It is prevented by good lubrication of the probe and gluing the probe so that it does not press on the nostril. The probe should always be thinner than the lumen of the nostril and should never be glued to the patient's forehead.
. Frequently monitoring the position of the probe in the nostril can help prevent this problem.

C. Sinusitis
. Develops with prolonged use of the probe.
. Remove the probe and place it in the other nostril.
. If necessary, treatment with antibiotics.

D. Entry of the probe into the trachea
. Leads to airway obstruction, which is easily diagnosed in a patient with preserved consciousness (cough, inability to speak).
. Before using an enteral feeding tube, obtain a chest x-ray to ensure the tube is in the correct position.

E. Gastritis
. Usually manifests itself as moderate bleeding from the upper gastrointestinal tract that stops on its own.
. Prevention consists of maintaining gastric pH>4.5 by administering antacids and intravenous H2 receptor blockers through a tube. The probe should be removed as quickly as possible.

F. Nose bleed
. Usually stops on its own.
. If it continues, remove the probe and determine the source of bleeding.
. Treatment of anterior and posterior nosebleeds.

Chen G, Sola HE, Lillemo KD.

If the patient, for a number of reasons, cannot eat food in the usual way, then special care is required regarding his feeding. It is for this purpose that nasogastric tubes for enteral nutrition were created. What are they and how do they work, are there any contraindications and difficulties in caring for them? product?

Nasogastric gastric tube - what is it?

This is a tube made of implantable non-toxic polyvinyl chloride (PVC), polyurethane or silicone, which is inserted through the nasal passage into the esophagus and then immersed in the stomach. Modern probes are available in various lengths and diameters, for adults and children. Thanks to modern materials that are resistant to hydrochloric acid produced in the stomach, a nasogastric feeding tube correct use can be used for 3 weeks.

Most often, such probes are intended for, i.e. for those cases when the patient cannot eat food in the usual way. Although sometimes the probe is used for other purposes:

• gastric decompression when it is difficult to remove its contents into the intestines,
• aspiration of stomach contents,

Nasogastric tube: indications

Why does regular eating become impossible? There are many diseases and conditions due to which this occurs:

• within complex therapy and pre- or postoperative stage during treatment intestinal obstruction ,
• acute pancreatitis,
• injuries to the tongue, pharynx, abdomen,
• postoperative period after resection of the stomach, intestines, pancreas, suturing of a perforated ulcer, other operations on the abdominal and thoracic cavities,
• unconsciousness (coma),
• mental illness accompanied by refusal to eat,
• swallowing problems due to disorders nervous regulation(diseases of the central nervous system, condition after a stroke),
• fistulas or strictures (narrowings) of the esophagus.

Most often they are intended for one-time use and must be disposed of immediately after feeding. Their advantage is the absence of phthalate, a large selection of sizes, and low price.

The polyurethane nasogastric tube is transparent and thermoplastic, i.e. due to the heat generated by the body tissues, it softens, which simplifies its use. Resistance to stomach acids allows the product to be installed for up to 30 days. An X-ray contrast line along the entire length of the probe helps the patient’s body not to lose it - during an X-ray examination, the product will always be visible.

Installation of a nasogastric tube

Preparation for installation begins with a conversation between the doctor and the patient or, if the patient is in unconscious- with his relatives. The doctor needs to explain why and how the tube will be installed, how it will function, and what nutrition can be administered through a nasogastric tube.

Then the doctor measures the distance from the throat to the stomach, but since... To do this, the patient needs to sit down, then in case of coma or lack of consciousness, the length of the probe is calculated using the formula height minus 100 cm. Before insertion, the probe is moistened with furatsilin solution to the desired level. It also needs to be placed in the freezer for an hour so that the probe becomes rigid enough for insertion, and the cold reduces the patient’s gag reflex.

Who places a nasogastric tube? This simple procedure is performed by a resuscitator or, if urgent need- doctor of any specialization, relatives. Introduction nasogastric tube It begins with the patient being placed on his back, with his head on a pillow, or placed half-sitting so that a slight tilt of the head helps free penetration of the probe into the nasopharynx. The procedure then goes through the following steps:

1. The patient first closes one nostril, then the other, and breathes a little, which is necessary to identify the most passable half of the nose.
2. The one who will insert the probe must.
3. Then measure the distance from the tip of the nose to the earlobe and put the first mark on the probe, then measure the distance from the incisors to the xiphoid process of the sternum and put the second mark.
4. For anesthesia, the nose and throat are treated with an anesthetic gel with lidocaine, the probe is also lubricated with this gel or glycerin.
5. The probe is inserted through the lower nasal passage to the level of the larynx, i.e. to the first mark. The patient should help by making swallowing movements. To make swallowing easier, you can drink water in small sips or through a straw.
6. Next, the probe is gradually advanced into the stomach - up to the second mark - and its position is checked. To do this, you can either aspirate the gastric contents with a syringe (i.e., lift it up the tube), or introduce 20-30 ml of air over the stomach area. A characteristic “gurgling” sound indicates that the tube is in the stomach.
7. The outer end of the probe must be pinned to clothing or skin, and then the cap must be closed.

If the patient is unconscious, then the doctor inserts two fingers of his left hand deep into the throat, pulls the larynx up and down back side fingers plunges the probe into the throat. In such a situation, there is a significant risk of the probe getting into Airways, and therefore the doctor must act carefully and carefully. Position The tube in the stomach is checked by x-ray.

Probe manipulations

The student must know:

purposes of probing the digestive tract;

technique for inserting a gastric tube through the nose or mouth;

technique for inserting a thick gastric tube through the mouth;

indications and contraindications for gastric lavage;

methods of taking gastric contents to determine secretion;

purposes of duodenal intubation;

universal precautions when working with obtained samples;

methods of decontamination of probes, funnels, syringes.

The student must be able to:

insert a thin probe into the stomach through the nose and through the mouth;

insert a thick probe into the stomach;

rinse the stomach;

take wash water for testing;

Explain to the patient the progress of the upcoming study of gastric contents and the contents of the duodenum and gall bladder;

Questions for self-study :

purposes, indications, contraindications of probe procedures;

deontological support of probe procedures;

equipment for probe manipulations;

algorithm for fractional sensing using the Leporsky method;

algorithm of action of fractional probing with a parenteral stimulus;

algorithm of action of duodenal intubation;

algorithm for gastric lavage;

positive and negative sides application of methods for studying gastric contents using the Leporsky method and with a parenteral stimulus.

nurse tactics in case of a patient’s reaction to histamine administration;

tactics of the nurse in case of absence of one of the portions during duodenal intubation (two possible reasons this);

the use of probeless methods, their positive and negative sides;

performing gastric lavage if the patient is unconscious;

vomiting and assistance with vomiting.

glossary

term

explanation

Atony

Weakening of tone, i.e. tension, excitability of tissues and organs

Hypokinesia

Insufficient movement

Intubation

Insertion of a special tube into the larynx

Cardia

The section of the stomach that comes after the esophagus

Regurgitation

Reverse current (liquids)

pH-metry

Determination of content pH various departments stomach and duodenum.

Stenosis

Narrowing of the lumen

Subcardinal section

Part of the stomach belowardia

Theoretical part

Ethical and deontological support

Many patients do not tolerate the insertion of the probe. This is caused by cough or gag reflexes, high sensitivity mucous membrane of the pharynx and esophagus. In most cases, poor tolerability of probe manipulations is caused by the patient’s negative psychological attitude towards the probing process; a “fear of examination” arises. To eliminate the “fear of research,” the patient should be explained the purpose of the study, its benefits, and speak politely, calmly, and kindly from the beginning to the end of the procedure.

Sample conversation content medical worker with the patient during insertion of the probe:

“We will now begin the procedure. Your well-being will largely depend on your behavior during probing. The first and basic rule is not to make sudden movements. Otherwise, nausea and cough may occur. You should relax and breathe slowly and deeply. Please open your mouth slightly and keep your hands on your knees. Breathe slowly and deeply. Take a deep breath and swallow the tip of the probe. If you have difficulty breathing through your nose, breathe through your mouth and gently advance the tube as you inhale. If you feel dizzy, breathe normally, shallowly, for a few minutes, then resume deep breathing. You swallow very well. It would be nice if other patients swallowed the tube just as easily.

Safety regulations

Attention !

If during any probe manipulation there is blood in the resulting material, stop probing and call a doctor!

If, when the probe is inserted, the patient begins to cough, choke, or his face becomes cyanotic, the probe should be immediately removed, since it has entered the larynx or trachea, and not the esophagus.

If the patient has an increased gag reflex, treat the root of the tongue with an aerosol 10% lidocaine solution.

Contraindications for all probe manipulations: gastric bleeding, varicose veins esophageal veins, tumors, bronchial asthma, severe cardiac pathology.

Probing of the digestive tract is carried out for both therapeutic and diagnostic purposes. With the help of intubation, you can obtain the contents of the stomach with its subsequent examination, and rinse the stomach. In case of acute dilatation (atony) of the stomach, especially in early postoperative period, in case of high intestinal obstruction, the contents, including gases, are removed using an inserted probe. With the help of a probe inserted into the stomach, one of the methods becomes possible artificial feeding patient. Medicines can be administered through a probe inserted into the digestive tract.

Fractional intubation of the stomach with a parenteral stimulus

Algorithm for inserting a gastric tube through the mouth

Purpose: research gastric juice, gastric lavage .

Contraindications: contraindications for all probe manipulations: gastric bleeding, varicose veins of the esophagus, tumors, bronchial asthma, severe cardiac pathology.

Equipment : Sterile gastric probe - rubber tube with a diameter of 3 - 10 mm. with lateral oval holes at the blind (inner) end. There are three marks on the probe: 1) 50-55cm (distance from the incisors to the entrance to the stomach); 2) 60-65cm (distance from the incisors to the stomach cavity); 3) 70-75cm (distance from the incisors to the exit from the stomach). Gloves, towel, glycerin.

Explain to the patient the procedure and obtain consent.

Open the package with the sterile probe. Remove it using sterile tweezers and place it in a sterile tray. Take the probe from the tray into right hand closer to the blind (inner) end, and with the left - to support the free end.

Explain to the patient, if possible, that:

• when inserting a probe, nausea and vomiting are possible, which can be suppressed by breathing deeply through the nose;

  Do not squeeze the lumen of the probe with your teeth and pull it out.

Note : if the patient behaves inappropriately, this procedure must be performed with the help of an assistant: means of fixing the arms and legs should be used, the assistant fixes the head with his hand. A mouth opener is used to hold the patient's mouth.

• Height - 100cm.

  The distance from the earlobe to the tip of the nose and to the navel.

  Up to 2 or 3 marks.

Moisten the inner end of the probe boiled water or glycerin.

Stand to the patient's right (if you are right-handed)

Invite the patient to open his mouth.

Place the end of the probe on the root of the tongue and invite the patient to swallow, breathe deeply and slowly through the nose (preferably).

Inject slowly and evenly to the desired mark.

Algorithm for obtaining material for research

(fractional sensing)

Equipment :

Sterile gastric probe - rubber tube with a diameter of 3 - 10 mm. with lateral oval holes at the blind (inner) end. There are three marks on the probe: 1) - 50-55cm (distance from the incisors to the entrance to the stomach); 2) - 60-65cm (distance from the incisors to the stomach cavity); 3) - 70-75cm (distance from the incisors to the exit from the stomach).

department______________ ward No.____

Referral to a clinical laboratory

gastric juice obtained with a parenteral irritant (pentagastrin)

9 servings

Patient: Full name__________________________

Date___________ Nurse's signature________

Glycerin is sterile.

Dishes: 9 clean jars or test tubes with labels.

Sterile syringe - 20.0 ml for extraction.

Sterile syringe - 2.0 ml for introducing the stimulus.

Irritant: histamine solution 0.1% or pentagastrin solution 0.025%.

Alcohol balls (alcohol - 70°).

Note: After each removal of gastric contents, the stomach must remain empty!

Fractional sounding using the Leporsky method

Purpose: study of gastric juice .

Contraindications : contraindications for all probe manipulations: gastric bleeding, tumors, bronchial asthma, severe cardiac pathology.

Equipment :

Thin sterile probe - rubber tube with a diameter of 3 - 5 mm. with lateral oval holes at the blind (inner) end. There are three marks on the probe: 1) - 50-55cm (distance from the incisors to the entrance to the stomach); 2) - 60-65cm (distance from the incisors to the stomach cavity); 3) - 70-75cm (distance from the incisors to the exit from the stomach).

Glycerin is sterile.

Dishes: 7 clean jars or test tubes with labels.

Sterile syringe - 20.0 ml or vacuum unit for extraction.

Gloves, towel, sterile tray, direction:

department________ ward No.___

Referral to the clinical laboratory of gastric juice obtained by the Leporsky method (cabbage broth)

1, 4, 5, 6 and 7 servings

Patient: Full name______________

Date of_____

Signaturem/s________

Enteral irritant - cabbage broth 200 ml, heated to 38°C.

Note : In addition to cabbage broth, enteral irritants can include: meat broth, caffeine solution, etc.

Algorithm for taking gastric juice using the Leporsky method

Explain to the patient the procedure for the procedure, warn in the evening that probing is done on an empty stomach, so that in the morning the patient does not eat, drink, or smoke anything(if probing is done in the office, then warn the patient not to forget to take a clean towel with him).

Correctly seat the patient: leaning on the back of the chair, tilting the head forward; if the patient is in bed, then a high Fowler position. If the patient cannot be placed in a sitting or reclining position, he can lie on his side without a pillow.

Wash your hands, put on gloves.

Place a towel on the patient’s neck and chest; if there are removable dentures, remove them.

Insert a tube (see algorithm for inserting a gastric tube through the mouth).

Using a 20.0 ml syringe, extract the contents of the stomach on an empty stomach -first a portion

Using the barrel of a 20.0 ml syringe (using it as a funnel, attaching it to the outer end of the probe), inject 200 ml of cabbage broth, heated to 38 ° C.

After 10 minutes, remove 10 ml of gastric contents -second a portion.

After 15 minutes, remove all stomach contents -third portion, the stomach should remain empty.

For an hour, every 15 minutes, use a 20.0 ml syringe to extract 4 more portions of stomach contents -fourth, fifth, sixth And seventh portions.

Carefully remove the probe using a towel or large napkin and place it in the disinfectant solution.

Wipe the patient's mouth and help him get into a comfortable position.

Remove gloves, place them in a disinfectant solution, and wash your hands.

Send to laboratory1, 4, 5, 6 and 7 portions along with direction.

When you receive a response from the laboratory, immediately paste it into the patient’s chart.

Remember ! With any method, you need to extract the contents as completely and continuously as possible! If a significant amount of blood appears, stop extraction, call a doctor, show the contents and act according to his instructions.

additional information

Equipping probe procedures for each patient individually.

Fractional research using the Leporsky method is currently rarely used due to technical inconvenience and less reliable research results.

Fractional study using parenteral stimuli:

1. Parenteral irritants are physiological, but are stronger than enteral ones, are precisely dosed, and when used, we obtain pure gastric juice. When histamine is administered, it is possible that side effects in the form of dizziness, feeling of heat, decreased A/D, nausea, difficulty breathing, etc. In case of these phenomena, you should urgently call a doctor and prepare one of the following for parenteral administration antihistamines: diphenhydramine, suprastin, pipolfen. Sometimes for warning purposes allergic reactions when using histamine, 30 minutes before its administration, inject a solution of diphenhydramine 1% - 1 ml subcutaneously.

   during collapse and anaphylactic shock- see algorithms for help with collapse and anaphylactic shock. Pentagastrin side effects almost doesn't cause it. It is administered subcutaneously at a dose of 6 μg (0.006 mg) per 1 kg of patient weight.

   The study is carried out in the morning on an empty stomach. The evening before the patient should not eat coarse, spicy food, and in the morning before the examination should not eat, drink, or smoke.

   In some cases, to make it easier to insert the probe into the stomach, the probe is placed in the freezer 1.5 hours before the procedure.

   After each removal of gastric contents, a clamp is applied to the outer end of the probe or it is bent and the patient holds the probe in his hand (if he is able), or tied it in a knot.

   After use, the probes are disinfected by boiling in distilled water for 30 minutes from the moment of boiling at complete immersion. Then they undergo pre-sterilization treatment, just like syringes (only they cannot be cleaned with brushes), and then hang-dried with the blind end up, individually packaged and sterilized by steam, gentle mode or 6% hydrogen peroxide (then they are not packaged).Order No. 345.

Can be disinfected in a 3% solution of samarovka for 1 hour.

Probes cannot be disinfected with chlorine-containing preparations, since the smell of chlorine from rubber is very difficult to remove.

All extracted portions of gastric contents are sent to the laboratory, where the quantity, color, consistency, smell, and the presence of impurities (bile, mucus, etc.) are determined. By titrating gastric juice with a 0.1 N sodium hydroxide solution, the free and total acidity in each portion is determined, and then the basal and stimulated production (output) of hydrochloric acid is calculated using the formula.

Unfortunately, in practice one often has to deal with erroneous results of fractional sounding. To avoid them, two circumstances must be taken into account. Firstly, the probe, after insertion into the stomach, may take an incorrect position (collapse, be in the upper part of the stomach, etc.). Therefore, if little gastric contents are obtained during suction, you need to inform your doctor. In this case, using x-ray examination You can check the position of the tube in the stomach. Secondly, the weak stimulants recommended so far gastric secretion(for example, cabbage broth, meat broth, caffeine, etc.) do not objectively reflect the state of gastric acid secretion. Histamine or (if there are contraindications) pentagastrin are used as a stimulant.

Probeless methods for studying gastric contents

Intracavity Ph -metry

One of modern methods studies of acid-forming and acid-neutralizing functions of the stomachis intracavitary Ph -metry - definition Phcontents of various parts of the stomach and duodenum by measuring the electromotive force generated by hydrogen ions. For this study, a specialPh-metric probe. Normal indicatorsPh usually 1.3 - 1.7.

IN last years both in our country and abroad this method of intracavitary (24-hour) continuous monitoringPhhas become widespread in specialized medical institutions. According to experts, the method is multi-purpose. Measurement phin the lumen of the stomach, esophagus or duodenum, carried out throughout the day, taking into account interdigestive and nocturnal acid secretion - the most dangerous when peptic ulcer- places this method among the most informative, accurate, and physiologically based.

Radiotelemetry method

R hGastric contents are sometimes determined using special “pills” (radio capsules) equipped with a miniature radio sensor. After swallowing such a radio capsule, the sensor transmits information aboutPh, temperature and hydrostatic pressure in the lumen of the stomach and duodenum, which is recorded by the receiving device.

In the morning on an empty stomach, the patient swallows a radiocapsule attached to a thin silk thread or a probe to hold the capsule in the desired part of the digestive tract. Then a belt is put on the patient, in which a flexible antenna is pre-mounted for receiving signals from the radio capsule, and the tape drive mechanism is turned on.

The radiotelemetric research method is the most physiological in studying the secretory and motor functions of the stomach.

"Acidotest"

The use of ion exchange resins for studying gastric secretion is based on the ability of the resins to exchange ions in an acidic environment. This principle is used in the Acidotest method. The method is based on the detection in urine of a dye formed in the stomach when an ingested ion exchange resin (yellow dragees) reacts with free hydrochloric acid. Caffeine (white tablets) serves as an enteral irritant. The color intensity is determined using a standard (color scale) in the laboratory.

The day before and on the day of the examination, the patient should not take medications or consume foods that color the urine. The study begins in the morning on an empty stomach, no earlier than 8 hours after eating.

Despite the fact that the “Acidotest” technique is not a probe procedure, the authors consider it possible to give it in this chapter.

Patient training in the “Acidotest” technique

(when carried out in outpatient setting)

Equipment: two containers for urine

Clarify the patient’s understanding of the progress and purpose of the upcoming study and obtain his consent.

Assess the patient's ability to learn.

Explain the “Acidotest” method:

• in the morning on an empty stomach (9 hours after the last meal) the patient empties bladder(this portion is not collected);

  After emptying your bladder, immediately take 2 caffeine tablets;

  empty your bladder after 1 hour into a glass container (mark it with a label that says “Control portion”);

  take 3 yellow tablets with a small amount of water;

  empty your bladder after 1.5 hours into a second container (mark it with a label that says “Experimental portion”);

  deliver to the laboratory the direction and containers with control and experimental portions of urine.

Ask the patient to repeat the “Acidotest” technique. Ensure that the training was effective. If necessary, provide written instructions.

Duodenal sounding

Probing of the duodenum is carried out to examine bile, which helps in the diagnosis of diseases of the biliary tract, gallbladder, pancreas and duodenum. Duodenal intubation is also used for therapeutic purposes (for example, to pump out bile with reduced motor function of the gallbladder).

Research is carried out using a special duodenal probe with a diameter of 4 - 5 mm and a length of up to 1.5 m, which has a metal olive with holes at the inner end. Such probes are made of rubber, but now probes are produced from polymeric materials; their olive is a brass alloy at the inner end. All duodenal tubes have marks every 10 cm.

The resulting portions of duodenal contents are subjected to microscopic examination, which makes it possible to identify inflammation in gallbladder and biliary tract (leukocytes, epithelial cells), detect various bacteria and protozoa (for example, Giardia). In addition, you can detect: atypical cells, cholelithiasis (by the presence of sand in the bile), determine a violation of the colloidal composition of bile (a large number of cholesterol crystals), etc.

As a rule, when performing duodenal intubation, three portions are obtained:

"A" – contents of the duodenum, its composition - duodenal juice + pancreatic juice + bile;

"IN" – bladder bile;

"WITH" – bile from intrahepatic bile ducts.

In some cases, a fourth portion appears - “VS”, the so-called bladder reflex, which usually occurs in children with gallbladder hypokinesia, and in adult patients with cholelithiasis.

Remember ! Portion “BC” is portion “C” against the background of portion “B” .

Considering the important diagnostic value this portion, the sister performing duodenalprobing,you need to observe the color of the bile when receiving portions “B” and “C”. The “BC” portion should be collected in a separate tube and marked accordingly.

In some diseases, for example, when the bile duct is blocked by a stone, it is not possible to receive portion “B”.

Algorithm for duodenal intubation

(fractional method)

Target : diagnostic .

Equipment : sterile duodenal tube in a package, a stand with test tubes, a stimulator for gallbladder contraction (25 - 40 mm 33% magnesium sulfate solution, or 10% alcohol solution of sorbitol or chylecystokinin), 20.0 ml syringe for aspiration, syringe for injection (if chylecystokinin is used ), heating pad, cushion, gloves, towel, small bench.

Clarify the patient’s understanding of the process and purpose of the procedure, obtain his consent to the procedure(if probing is done in the office, then warn the patient not to forget to take a clean towel with him).

Wash your hands, put on gloves.

Invite the patient to sit on a chair or couch.

Place a towel on the patient's chest.

Open the package with the sterile probe, take the inner end of the probe in your right hand at a distance of 10 - 15 cm, hold the outer end with your left hand.

Determine the distance to which the patient should swallow the probe so that it is in the subcardinal part of the stomach (on average about 45 cm) and in the duodenum: the distance from the lips and down the anterior abdominal wall so that the olive is located 6 cm below the navel.

Invite the patient to open his mouth, place the olive on the root of the tongue, the patient swallows the olive, the nurse helps him swallow, carefully moving the probe deeper. The patient continues to swallow. With each swallowing movement, the probe will move into the stomach to the desired mark (4th or 5th). The patient can sit or walk while the tube is being swallowed.

Check the location of the probe by connecting a syringe to the outer end and aspirate the contents. If the syringe receives a cloudy liquid yellow color- olive is in the stomach; if not, pull the probe towards you and ask him to swallow the probe again.

9. If the probe is in the stomach, place the patient on the right side, placing a cushion or blanket under the pelvis, and under the right hypochondrium. warm heating pad. In this position, the patient continues to swallow the probe until the 7th - 8th mark. Duration of ingestion is from 40 to 60 minutes.

Note : A rack with test tubes is installed below the level of the couch. When the olive is in the duodenum, a golden-yellow liquid enters the test tube - duodenal contents - portion A . In 20 - 30 minutes, 15 - 40 ml of duodenal contents (2 - 3 tubes) are delivered. If the liquid does not enter the test tube, you need to check the location of the probe by injecting air into it with a syringe and listening to the epigastric region with a phonendoscope. If the probe is in the duodenum, then the insertion of the probe is not accompanied by any sounds; if the probe is still in the stomach, then when air is introduced, characteristic bubbling sounds are noted

10. When swallowing the probe to the 9th mark (80 - 85 cm), lower the outer end into the test tube.

11. After receiving the portion"A" , use a syringe to inject a gallbladder contraction stimulator (25 - 40 ml of 33% magnesium sulfate solution, or 10% alcohol solution sorbitol, or cholagogue hormonal nature, for example, cholecystokinin – 75 units. i/m). Move the probe to the next tube.

12. 10 - 15 minutes after the introduction of the stimulant, a portion will begin to flow into the test tube« IN" – bladder bile. Duration of receiving portion« IN" – in 20 - 30 minutes. – 30 - 60 ml of bile (4 - 6 tubes).

Note : for timely detection of portions " Sun" carefully observe the color of the portion « IN" . When liquid appears light color, move the probe to another tube, then, when liquid appears dark color– move the probe again. Mark portion "Sun" .

13. After receiving the portion« IN" move the probe to the next test tube to obtain a portion « WITH" – liver portion. Duration of receiving portion« WITH" – in 20 - 30 minutes - 15 - 20 ml (one - two test tubes).

14. Carefully remove the probe using a towel or napkin using slow progressive movements, while wiping it.

15. Immerse the probe in the disinfectant solution.

16. Wash your hands, remove gloves, place them in a disinfectant solution, wash and dry your hands.

17. Send all portions to the clinical and bacteriological laboratories with directions.

18. When receiving an answer from the laboratory, immediately paste it into the patient’s chart.

department_______ ward No.___

Referral to clinical

Laboratory

Patient name_______________

department_______ ward No.___

Referral to bacteriological

Laboratory

Bile - portions “A”, “B”, “C”.

Patient name_______________
date________ signature m/s_____

Bile delivered to the laboratory is examined:

determine physical properties(color!. transparency, quantity" specific gravity, reaction);

carry out a chemical study (study of the concentration function of the gallbladder, colloidal stability of bile (determination of protein, bilirubin, urobilin, bile acids, cholesterol));

Normal bile contains almost no cellular elements and sometimes contains a small amount of cholesterol.

In case of pathology, the contents appear leukocytesLeukocytes: White blood cells. In an adult healthy person 1 μl of blood contains 5-9 thousand L. The amount of L. can either increase (leukocytosis) or decrease (leukopenia). In an adult, leukocytes are formed mainly in bone marrow. Leukocytes have amoeboid movements and take part in immune reactions. Define leukocyte formula: quantitative relationship between separate forms L., detected when clinical analysis blood is essential in determining the disease. Depending on the structure and functions performed, L. are divided into granulocytes and agranulocytes: granulocytes make up 60% of all L. Their cytoplasm has a granular structure. Granulocytes are divided into three types: basophils (produce heparin, which prevents blood clotting), neutrophils (perform a phagocytic function, accumulating in areas of tissue damage or penetration of microbes into the body), eosinophils (participate in the neutralization and destruction of foreign proteins). Agranulocytes (non-granular leukocytes) are divided into lymphocytes and monocytes. Lymphocytes are formed in lymph nodes, tonsils, spleen and bone marrow. Various groups lymphocytes react differently to a foreign protein, producing either enzymes that destroy protein bodies (microbes, viruses) or specific antibodies that bind and neutralize the foreign protein. Monocytes have amoeboid movements and are characterized by high phagocytic activity, but under conditions other than neutrophils, appearing in the site of inflammation at the final stage and preparing this area for regeneration.» | mucus, epithelium - signs of inflammation; red blood cells, cholesterol crystals, bilirubin - signs cholelithiasis.

Portion A is obtained from the duodenum - the pathology in it confirms the pathology in portions B and C or the pathology of the stomach and duodenum.

Portion C - from intrahepatic bile ducts; disease - cholangitis.

If you can't get portion B, you can think about hypertensive form biliary dyskinesia. If portion B is excessively abundant, one can think of a hypotonic form of dyskinesia.

If protozoa Giardia or helminths (opisthorchiasis) are detected, this is a possible etiology of the disease.

Gastric lavage

At acute poisoning large doses medicines taken orally, poor quality food, alcohol, mushrooms, etc., the stomach is lavaged through a thick or thin tube. (At the same time, experts in the field of toxicology consider gastric lavage with a thick probe to be an unsafe procedure).

Remember ! Gastric lavage for an unconscious patient in the absence of cough and laryngeal reflexes to prevent aspiration of fluid is carried out only after preliminary intubation of the trachea, which is performed by a doctor or paramedic.
If, when the probe is inserted, the patient begins to cough, choke, or his face becomes cyanotic, the probe should be immediately removed - it has entered the larynx or trachea.

Decontamination of probes is carried out in accordance with available regulatory documents. Each probe must be packaged in a separate bag. In the same bag, it is cooled in the freezer for 1.5 hours before insertion, which greatly facilitates the procedure for inserting the probe.

Algorithm for gastric lavage with a thick probe

Goal: cleanse the stomach of poisons and toxins.

Indications :

Contraindications:

Equipment : gastric lavage system (2 thick - up to 1 cm in diameter sterile gastric probes connected by a glass tube, the blind end of one probe is cut off), a glass funnel with a capacity of 1 - 1.5 liters, a towel, napkins, a sterile container for rinsing water (if you will need to send them to the laboratory), a container with water T° - 18° - 25° - 10 l, a mug, a container for draining wash water, gloves, 2 waterproof aprons, glycerin.

Note :

Disconnect the funnel and remove the probe using a towel or napkin. Place contaminated items in a waterproof container. Pour the rinsing water down the drain.

Remove gloves, wash hands.

Gastric lavage with a thin probe

Goal: cleanse the stomach of poisons and toxins .

Indications : acute poisoning with large doses of drugs taken orally, poor quality food, alcohol, mushrooms, etc.

Contraindications: organic narrowing of the esophagus, acute esophageal and stomach bleeding, heavy chemical burns mucous membrane of the larynx, esophagus, stomach with strong acids and alkalis (several hours after poisoning), myocardial infarction, violation cerebral circulation, malignant tumors stomach, esophagus, pharynx.

Equipment : thin gastric tube, Janet syringe, towel, napkins, sterile container for washing waters (if you need to send them to the laboratory), container with water T° - 18° - 25° - 10 l, container for draining washing waters, gloves, 2 waterproof apron, glycerin.

Clarify with the patient the understanding of the course and purpose of the manipulation (if the patient is conscious) and obtain his consent.

Wear aprons for yourself and the patient.

Wash the hands hygienic level, put on gloves, treat gloves with antiseptic for gloves.

Insert the gastric tube to the established mark through the mouth or through the nose (see the algorithm for inserting the gastric tube through the mouth or through the nose).

Fill the Janet syringe with 0.5 liters of water, attach it to the probe and inject the water into the stomach.

Pull the piston towards yourself, aspirating (removing) the injected water from the stomach.

Note : if necessary, take washing water for examination (as prescribed by a doctor):

reintroduce this portion of liquid into the stomach;

if poisoning with cauterizing poisons is suspected, immediately take the first portion of rinsing water;

repeat steps 5 - 6 twice and pour the rinsing water into a sterile container and close the lid.

Note : If blood appears in the rinsing waters, immediately inform the doctor without removing the probe, show the rinsing waters to the doctor!

Repeat the introduction of water into the stomach and its aspiration until the rinsing water is clean (all 10 liters of water must be consumed).

Disconnect the Janet syringe and remove the probe using a towel or napkin. Place contaminated items in a waterproof container. Pour the rinsing water down the drain.

Remove aprons and place them in a waterproof container

Wash the patient, lay him comfortably on his side, and cover him.

Remove gloves, wash hands.

Write a direction and send the wash water to the laboratory.

Make a record of the procedure and the patient’s reaction to it in the medical record.

View on the website:

http://video.yandex.ru/users/nina-shelyakina/collections/?p=1 in the collectionPM 04 films numbered 192, 193, 194 and repeat all the manipulations on the topic.

From the Internet

DUODENAL PROBING

In what cases is duodenal intubation indicated for a patient?
Duodenal intubation is carried out for diseases of the liver and biliary tract, both diagnostic and medicinal purposes. At the same time, in duodenum or parenterally introduce various irritants that stimulate contractions of the gallbladder, relaxation of the sphincter of the common bile duct and the passage of bile from the biliary tract into the duodenum.
What substances are used as irritants introduced into the duodenum during duodenal intubation?
30-50 ml of warm 25% magnesium sulfate solution is used as irritants. 2 ml are administered parenterally. gastrocepin.
What is a duodenal intubation probe?
For duodenal intubation, a sterile disposable probe with a diameter of 3 ml and a length of 1.5 m is used. At its end, inserted into the stomach, a hollow metal olive with a number of holes is fixed. There are 3 marks on the probe: at a distance of 40-45 cm from the olive, 70 cm and 80 cm from the olive. The last mark approximately corresponds to the distance from the front teeth to major papilla duodenum (papilla of Vater).
How do you prepare for the probing procedure?
In addition to the probe, a clamp for the probe, a stand with test tubes, a syringe with a capacity of 20 ml, sterile test tubes for inoculation, a tray, and medications (25% magnesium sulfate solution) are prepared for the duodenal intubation procedure.
To prepare for the study, the patient is prescribed 2 tablets of no-shpa orally the night before. Dinner - light; gas-forming products (brown bread, milk, potatoes) are excluded.
How is the duodenal intubation procedure performed?
The study is carried out on an empty stomach. Mark on the probe the distance from the navel to the front teeth of the patient, who is in a standing position. After this, the patient is seated and a tray with a probe is given into his hands. An olive is placed deep behind the root of the patient’s tongue, inviting him to swallow and breathe deeply (the olive can be lubricated with glycerin beforehand). Subsequently, the patient slowly swallows the tube, and when gagging occurs, he clamps it with his lips and takes several deep breaths. When the probe reaches the first mark, the olive is presumably in the stomach. The patient is placed on the couch on his right side, under which a cushion of rolled up blanket or pillow is placed (at the level of the lower ribs and right hypochondrium). A hot heating pad wrapped in a towel is placed on top of the roller.
What is portion A during duodenal intubation?
If the olive enters the intestine, a golden-yellow transparent liquid begins to be released - portion A (a mixture of intestinal juice, pancreatic secretion and bile). The liquid flows freely from the outer end of the probe lowered into the test tube, or it is sucked out with a syringe. A test tube with the most transparent contents is selected for analysis.
How is portion B collected during duodenal intubation?
One of the irritants is introduced through a probe (usually 40-50 ml of a warm 25% solution of magnesium sulfate). The probe is closed with a clamp (or tied in a knot) for 5-10 minutes, then opened, the outer end is lowered into a test tube and concentrated dark olive bladder bile is collected (second portion - B). If this does not happen, you can repeat the administration of magnesium sulfate after 15-20 minutes.
How is portion C collected during duodenal intubation?
After the gallbladder is completely emptied, golden-yellow (lighter than portion A), transparent, without impurities, portion C begins to flow into the test tubes - a mixture of bile from intrahepatic biliary tract and duodenal juices. After receiving this portion, the probe is removed.
How is material collected for bacteriological research?
For bacteriological examination, part of the bile from each portion is collected in sterile tubes. Before and after filling the tubes with bile, their edges are held over the flame of the burner and all other rules of sterility are observed.
The resulting portions of duodenal contents should be delivered to the laboratory as quickly as possible, since the proteolytic enzyme of the pancreas destroys leukocytes. Giardia is difficult to detect in cooled duodenal contents because they stop moving. To prevent cooling, the test tubes are placed in a glass with hot water(39-40 °C).
How is the assessment carried out? functional state biliary system based on duodenal intubation data?
The receipt of bile indicates the patency of the bile ducts, and portions B indicate the preservation of the concentration and contractile function of the gallbladder. If within 2 hours it is not possible to advance the olive of the probe into the duodenum, the study is stopped.
What is chromatic duodenal sounding?
For more accurate recognition of cystic bile, chromatic duodenal sounding is used. To do this, the night before, approximately 12 hours before the test (at 21.00-22.00, but not earlier than 2 hours after a meal), give the test subject 0.15 g of methylene blue in a gelatin capsule.
In the morning, when the bladder is probed, the bile turns out to be blue-green. The time elapsed from the moment of introduction of the stimulus until the appearance of portion B and the volume of bile are determined.
What are the features of duodenal intubation in children?
In children, duodenal intubation is as difficult as extracting gastric juice. An olive probe is inserted into newborns to a depth of approximately 25 cm, children 6 months old - 30 cm, 1 year old - 35 cm, 2-6 years old - 40-50 cm, older children - 45-55 cm. Magnesium sulfate is injected into duodenum at the rate of 0.5 ml of 25% solution per 1 kg of body weight. Otherwise, the procedure and probing technique are the same as for adults.

Equipment: gastric tube with a diameter of 0.5 - 0.8 cm (the tube must be in the freezer for at least 1.5 hours before the procedure; in an emergency, the end of the tube is placed in a tray with ice to make it harder); sterile petroleum jelly or glycerin; a glass of water 30-50 ml and a drinking straw; Janet syringe with a capacity of 20 ml; adhesive plaster (1 x 10 cm); clamp; scissors; probe plug; safety pin; tray; towel; napkins; gloves.

I. Preparation for the procedure

1. Clarify with the patient the understanding of the course and purpose of the upcoming procedure (if the patient is conscious) and his consent to the procedure. If the patient is uninformed, clarify further tactics at the doctor's.
2. Determine the half of the nose most suitable for inserting the probe (if the patient is conscious):
   • first press one wing of the nose and ask the patient to breathe with the other, closing his mouth;
   • then repeat these steps with the other wing of the nose.
3. Determine the distance to which the probe should be inserted (the distance from the tip of the nose to the earlobe and down the anterior abdominal wall so that the last hole of the probe is below the xiphoid process).
4. Help the patient assume a high Fowler's position.
5. Cover the patient's chest with a towel.

Rice. 7.1. Insertion of a nasogastric tube

II. Executing the procedure

1. Wash and dry your hands. Wear gloves.
2. Liberally coat the blind end of the probe with glycerin (or other water-soluble lubricant).
3. Ask the patient to tilt their head back slightly.
4. Insert the probe through the lower nasal passage to a distance of 15-18 cm and ask the patient to tilt his head forward.
5. Advance the probe into the pharynx along the back wall, asking the patient to swallow if possible.
6. Immediately, as soon as the probe is swallowed, make sure that the patient can speak and breathe freely, and then gently advance the probe to the desired level.
7. If the patient can swallow:
   • Give the patient a glass of water and a drinking straw. Ask to drink in small sips, swallowing the probe. You can add a piece of ice to the water;
   • ensure that the patient can speak clearly and breathe freely;
   • gently move the probe to the desired level.
8. Help the patient swallow the probe by moving it into the pharynx during each swallowing movement.
9. Make sure the tube is positioned correctly in the stomach:
   1. introduce about 20 ml of air into the stomach using a Janet syringe, while listening to the epigastric region, or
   2. attach the syringe to the probe: during aspiration, the contents of the stomach (water and gastric juice) should flow into the probe.
10. If necessary, leave the probe on long time: cut the plaster 10 cm long, cut it in half at a length of 5 cm. Attach the uncut part of the adhesive plaster to the back of the nose. Wrap each cut strip of adhesive tape around the probe and secure the strips crosswise on the back of the nose, avoiding pressing on the wings of the nose.
11. Cover the probe with a plug (if the procedure for which the probe was inserted will be performed later) and attach it with a safety pin to the patient's clothing on the shoulder.

III. Completing the procedure

1. Remove gloves. Wash and dry your hands.
2. Help the patient find a comfortable position.
3. Make a record of the procedure and the patient's reaction to it.
4. Rinse the probe every four hours with isotonic sodium chloride solution 15 ml (for a drainage probe, introduce 15 ml of air through the outflow outlet every four hours).

Note. Care for a probe left in place for a long time is the same as for a catheter inserted into the nose for oxygen therapy.