Table 1 Eight Steps of the New Flushing Protocol, with Rationale

1. During flushing, change suction to continuous. Be sure that the tubing is not clogged.

So that suction does not turn off during the subsequent steps below.

2. Inject 120 mL warm tap water and 120 mL air into larger (clear, suction) port.

So that the stomach lining is pushed away from the tube, and so that there is an adequate volume in the stomach to suction out.

3. Reapply continuous suction; observe and note the character and amount output (Suctioned volumes are not re-administered to the patient).

So that the volume of water injected and gastric fluid already present is suctioned out. Sometimes, repeating step 2 is necessary to get this volume to suction out.

4. Flush 60 mL air into smaller (blue or clear, air-sump) port and watch for air to suction out larger (clear, suction) port.

If the NGT is in an empty stomach, the air injected in the small port will enter the stomach, suction out the suction port, and be seen as large bubbles of air in the suction tubing, but if the NGT is at the bottom of a pool of liquid, this will not happen because the air will simply bubble to the top of the gastric pool.

5. May repeat the 60 mL air into smaller (blue or clear, air-sump) port x3.

Sometimes more air is needed; may also repeat step 2 again here.

6. Call ordering physician if air flushed into smaller (blue or clear, air-sump) port is not suctioned out through larger (clear, suction) port.

Because this means that the stomach may be full of liquid and dangerously distended.

7. If air flushed into smaller port is seen to suction out through the larger port, then intake and output may be recorded, and GRV calculated by subtracting flush volume from total volume suctioned (all flushes should be recorded as intake, and all aspirate as output).

If air flushed into smaller port is immediately suctioned through larger port, then the stomach is empty (Fig. 4a).

8. Return suction to low intermittent suction.

Intermittent is better than continuous suction because intermittent lapses in allow the stomach lining is allowed to fall away from the suction holes of the NGT.