Gastric lavage

Authors: Rednenko V.V., Rednenko L.I., Poplavets E.V.

Editor: Rednenko V.V.

Equipment for the practical skill:

• simulator for a gastric lavage 
• manipulation table
• chair (bed)
• syringe (Janet's syringe) of the volume at least 100 ml
• gastric lavage tube of an appropriate size (large-bore orogastric tube)
• large funnel (Esmarch's irrigator) with connector for tube
• bucket with water (6-8 l)
• measuring cup for water (not less than 700 ml)
• containers for specimens
• container for aspirate (basin)
• thermometer for water
• PPE: medical gown, hat, mask, non-sterile gloves, two aprons, sleeve protectors
• skin antiseptic
• towel (gauze pad)
• waste containers
  • "Empty vials"
  • "Packaging"
  • "Plastic"
• working solution of a chemical disinfectant in containers:
  • "Rinsing of MI"
  • "Disinfection of MI"
  • "Disinfection of dressings, PPE"
• medical records

Clinical situation:

• Patient A., 65 years old, was admitted to the infectious diseases department of the central district hospital by a ambulance with diagnos "Acute oral poisoning". The patient is conscious. He complains of general weakness, nausea, retching, headache. Coordination broken.  Blood pressure 110/60 mmHg. Pulse 100  per min. According to the patient about 30 minutes ago, he drank 350 ml of alcohol of unknown origin. 
• Сarry out a gastric lavage.

Order of the skill performance:

Note. The actions indicated in this text, performed by the right hand, are performed by left-handers with the left

Preparatory stage:

• Check the equipment at the workplace, complete the workplace if necessary
• Put on your protective equipment
  • Put on an apron
  • Perform hygienic handrub
  • Put on your gloves
• Identify the patient
  • say hello to the patient, introduce yourself;
  • specify the last name, first name and patronymic of the patient, check the prescription sheet
  • Get informed consent
  • Inform the patient about the upcoming manipulation,
  • Obtain verbal consent to conduct it
• Prepare the patient for the procedure
  • Help the patient to get into the required position:
    • in a satisfactory condition - sitting on a chair (the back should be pressed tightly against the back of the chair)
    • in severe condition - lying on its side (without a pillow)
    • in case of unconsciousness - in the supine position after preliminary tracheal intubation (in order to prevent aspiration of gastric contents)
  • Ask the patient to rinse his mouth with water from a glass, make sure that there are no removable dentures (if available, suggest removing)
  • Check the patient's weight and calculate a single (single) dose of water (at the rate of 5-7 ml per 1 kg of patient weight)
  • Sit the patient on a chair (lay on a couch),
  • Place a basin between your legs (put your pelvis next to the couch),
  • Put an apron on the patient, lowering its lower edge into the basin
• Prepare equipment for the procedure
  • Check the temperature of the water in the bucket: lower the thermometer into the bucket, remove it, evaluate the result, put the thermometer on the manipulation table
  • Prepare Janet's syringe: open the package, remove the syringe, remove the cap (if any), place the cap in the appropriate container, put the syringe back in the package
  • Prepare the gastric lavage tube:
    • open the package, remove the tube (the distal end of the tube should not touch the outer surface of the package), holding the end of the tube with the connector with your left hand, take the tube with the first, second and third fingers of your right hand at a distance of 10 cm and straighten it along the length
    • measure the length of the tube corresponding to the depth of insertion into the stomach in one of the following ways:
      • Method 1 - bring the tube to the patient and, without touching the patient, measure the distance from the tip of the nose to the earlobe and to the lower edge of the xiphoid process of the patient
      • 2nd method - bring the tube to the patient and, without touching the patient, measure the distance from the nose bridge to the navel
    • remember the desired label (when using a probe without a label, put a label with a marker or a thin strip of adhesive plaster)

Maine stage:

• Insert the tube into the stomach
  • Take the tube in your right hand like a "pen" at a distance of 10 cm from the distal (rounded) end
  • Moisten the distal end of the tube with water by dipping it in a bucket of water
  • Stand to the side of the patient (right-handed - to the right, left-handed - to the left of the patient), invite the patient to open his mouth wide
  • Insert the distal end of the tube into the patient's mouth by the root of the tongue, holding the patient's head with the left hand
  • Offer the patient to swallow without squeezing the tube with his teeth and breathe deeply through the nose (giving the patient the command "SWALLOW!", Try to quickly pass the tube)
  • Insert the tube into the stomach up to the mark (the mark should remain at the level of the incisors):
  • in case of cough, shortness of breath, cyanosis of the face - remove the tube immediately
  • if there is a urge to vomit, pause the insertion of the tube a little, invite the patient to take a few deep breaths and exhales through the nose, then continue inserting the tube
• Check if the end of the tube is in the stomach in one of the following ways:
  • first way:
    • put on the phonendoscope
    • take the syringe from the package, draw 30-40 ml of air into it
    • attach the syringe to the tube connector, take the syringe in your right hand
    • place the phonendoscope membrane with your left hand on the anterior abdominal wall in the epigastric region
    • quickly enter the air into the stomach, pressing the plunger of Janet's syringe with the thumb of his right hand, while listening to the phonendoscope for the characteristic sounds of "gurgling" in the epigastric region
    • Disconnect Janet's syringe from the tube connector with your right hand, holding the connector with your left hand, and place the syringe in the tray
    • remove the phonendoscope, place it on the top shelf of the manipulation table
  • second way:
    • take Janet's syringe from the package and attach it to the tube connector
    • pull the plunger of Janet's syringe towards you: when the tube is in the stomach cavity, the gastric contents enters the syringe
    • disconnect Janet's syringe from the tube
    • drain the contents of Janet's syringe into a basin, if necessary take the aspirate for exam - into a container for specimen
• Perform a gastric lavage in one of the following ways:
  • the first way - using Janet's syringe:
    • fill Janet's syringe with water from a bucket and attach it to the tube connector
    • inject water into the stomach: placing the second and third fingers of the left hand on the connector, hold the syringe barrel with the first, fourth and fifth fingers of the left hand, press the syringe plunger with the fingers of your right hand
    • disconnect Janet's syringe from the connector, re-draw water from the bucket into the syringe, attach the syringe to the connector and re-enter the water into the stomach
    • repeat the intake of water into the syringe and the introduction of water into the stomach until a single volume of water is reached (the maximum single volume is no more than 7 ml per kg of the patient's body weight)
    • upon reaching the single volume, pull the plunger of Janet's syringe towards you along the entire length of the plunger to aspirate rinsing water
    • if it is necessary to study the wash water, drain the aspirate into a container for for specimen, tightly closing the container with a lid, followed by delivery of the biological material in the container for transporting samples (if the aspirate was taken at the stage of checking the tube location in the stomach, drain the aspirate into the basin)
    • re-attach Janet's syringe to the tube connector and pull the plunger towards you
    • drain the contents of Janet's syringe into a basin (the amount of rinsing water should correspond to the amount of liquid injected)
    • when stopping the flow of gastric contents into Janet's syringe, stop pulling back the plunger
    • repeat washing until clean wash water is obtained
    • disconnect Janet's syringe from the tube connector by placing the syringe in the tray
  • the second method is using a funnel (Esmarch's irrigator) and a measuring cup for water:
    • fill the measuring cup from the bucket with the required volume of water, corresponding to the one-time volume
    • attach a funnel (Esmarch irrigator) to the probe connector
    • lower the funnel (Esmarch's irrigator) below the level of the stomach
    • fill the funnel (Esmarch's irrigator) with water, holding it obliquely and gradually leveling it (so that air does not enter the stomach when filling the funnel with water)
    • slowly lift the funnel (Esmarch mug) up (above the stomach level) so that the water reaches the mouth of the funnel (Esmarch mugs)
    • control the exit of water from the funnel (Esmarch's irrigator): in order to avoid air entering the tube, do not allow water to completely leave the funnel (Esmarch mugs), which will complicate the removal of gastric contents
    • lower the funnel (Esmarch's irrigator) below the level of the stomach and let it completely fill with rinsing water (the amount of rinsing water should correspond to the amount of liquid injected)
    • take 100-200 ml of wash water into a prepared container to be sent to the laboratory (if it was not performed at the stage of checking the location of the tube in the stomach)
    • the rinse water remaining in the funnel (Esmarch's irrigator) drain into the basin
    • after the appearance of clean wash water, disconnect the funnel (Esmarch's irrigator) by placing it in the container "Disinfection MI"
• Complete the procedure 
  • ask the patient about the end of the manipulation
  • take a towel (gauze pad) from the package, place it on the tube and through the gauze pad, remove the tube from the patient's stomach smoothly, without sudden movements, examine it for blood
  • place the gauze pad in the container "Disinfection of dressings, PPE"
  • ask the patient about his health, give the patient a glass for mouthwash and a  towel (gauze pad), suggesting to dry the skin around the mouth, then place the gauze pad in the container "Disinfection of dressings, PPE"

Final stage:

• take Janet's syringe, attach it to the tube connector and use Janet's syringe to rinse the tube in the container "Rinsing of MI"
• fill the channel of the tube with a syringe Janet with a chemical disinfectant from the container "Disinfection MI"
• place the tube, Janet's syringe disassembled and the tray in the container "Disinfection MI"
• put the packages from MI into the container for collecting packages
• take off the apron (waterproof) from the patient and place it in the container "Disinfection of dressings, PPE"
• wash the bucket with running water, put it in a storage place (when washing with Janet's syringe, disinfect the bucket by wiping or irrigation)
• pour the rinsing water from the basin into the sewer, disinfect the basin by wiping or irrigation
• remove the apron and place it in the container "Disinfection of dressings, PPE" (disinfect the reusable apron by wiping or irrigation)
• remove gloves and place in container "Disinfection of dressings, PPE"
• perform hygienic handrub
• when using the measuring cup for water, rinse it with running water and place it in storage
• disinfect the outer surface of the table using the manipulative method of wiping or irrigation and the subsequent stages of disinfection of the MI
• if it is necessary to exam wash water, fill out the referal for the exam of biological material and the list of the biomaterial sent to the laboratory, put the list and the referal in a separate package to the container for transportation