Nasogastric Tube Placement

Aspiration of gastric fluid, air, or blood

Evaluation of upper gastrointestinal (GI) bleed (volume and/or presence of blood)

Decompression of obstructed GI tract (i.e., small bowel obstruction)

Prevention of aspiration and gastric dilatation (i.e., in intubated patients)

Lavage or removal of toxins (e.g., overdose, poisonings)

Administration of medication, oral contrast, and nutrients (TABLE 31.1)

CONTRAINDICATIONS

Absolute Contraindications

Facial trauma with possible cribriform-plate fracture

Concern for passage into intracranial space

Relative Contraindications

Severe coagulopathy

If critical, consider the orogastric route, which may cause less bleeding

Alkali ingestions or esophageal strictures

Placement may cause esophageal rupture

History of gastric bypass surgery/lap band placement

Risk for intestinal perforation

General Basic Steps

Position patient

Analgesia

Measure nasogastric tube (NGT)

Insertion

Confirmation of placement

Secure tube

EQUIPMENT NEEDED

NGT

Viscous lidocaine

Cetacaine spray (optional)

Nebulizer equipment and 4% lidocaine (optional)

A cup of water with straw

Tapered syringe (30–60 cc)

Suction

Tape

TABLE 31.1.

COMMON REASONS FOR NGT PLACEMENT

Bright red blood per rectum

Hematemesis/Coffee-ground emesis

Small bowel obstruction

Intubated patient

TECHNIQUE

Patient Preparation

Elevate the head of the patient’s bed to upright position (if possible)

Place an emesis basin on the patient’s lap

Select the patent nostril for tube placement

Have the patient occlude one nostril at a time and sniff

It may be necessary to switch to the opposite nostril if one side proves to be too difficult

In awake patients, anesthetize selected nare at least 5 minutes before attempting tube placement

Inject lidocaine gel (5 mL of 2% viscous lidocaine) via a 10-mL syringe. Ask the patient to sniff and swallow. The patient can orally swallow additional 5 mL of viscous lidocaine to further anesthetize the posterior pharynx.

Consider using benzocaine (Cetacaine) spray on the posterior pharynx

Consider nebulized lidocaine (2.5 mL of 4% lidocaine) via a face mask as an alternative to gels and sprays

Immediately after opening the NGT package, place the small (easily misplaced) “connector” in a safe place; it is frequently missing/lost when you want to connect the NGT to suction

Estimate tube insertion distance

Measure the tube from the patient’s xiphoid process to the earlobe through the tip of the nose. Add 15 cm to this distance and mark on the NGT with a small amount of tape.

Lubricate NGT with viscous lidocaine or Surgilube

Insertion

Insert the tube (usual adult size 16-French or 18-French) into the selected nostril, aiming along the floor of the nose, posteriorly and caudally

Once in the nasopharynx, have the patient flex his head forward to aid tube placement into the esophagus

Pause as the tube enters the oropharynx and have the patient swallow water via straw to aid in the passage of tube, and then rapidly advance the tube into the stomach to the predetermined depth

Confirmation of Placement

Patient is able to speak clearly

If the patient has difficulty speaking or is coughing, the tube is likely in the trachea and needs to be removed

Aspirate gastric contents

Insufflation of air through a 50- or 60-mL syringe into the end of the NGT while auscultating over the stomach should reveal borborygmi (gurgling in stomach)

If the patient burps after insufflation, the tube is likely in the esophagus and needs to be advanced

Secure the Tube

Clean and dry the tube, if necessary

Tape the NGT at the nose entry site with emphasis of alleviating pressure of the tube on the nose

Secure the tube to the patient’s gown for added stability

The air vent pigtail can be used as a cap for suction lumen when the tube is not in use

Chest X-ray Confirmation

It is not required to routinely confirm NGT placement with chest x-ray as the tube can be clinically confirmed via aspiration of gastric contents

If a chest x-ray is planned for endotracheal tube placement, consider obtaining after NGT placement

If the patient is unconscious, consider x-ray confirmation, especially if charcoal is to be administered through the NGT

COMPLICATIONS

Epistaxis

Tracheal intubation

Esophageal/gastric perforation

Aspiration

Sinusitis or otitis media

Ulceration of mucosa

Esophageal stricture

Necrosis or bleeding of nasal mucosa from improperly secured tube

Intracranial insertion

SAFETY/QUALITY TIPS

Procedural

The keys to success are adequate anesthesia and cooperation, tilting the head forward, and having the patient swallow water as tube is advanced

While passing the NGT, point the proximal end of the tube away from staff and self; vomiting during insertion can spray out of the proximal tube end

Consider using a sedative in patients who have difficulty tolerating the procedure

In the intubated, nonagitated, and noncombative patient, gently lifting the jaw forward or pushing the trachea to the patient’s left can ease the passage of the NGT

An alternative method of orogastric tube (OGT) placement in an intubated patient is performing laryngoscopy and placing the tube into the esophagus under direct visualization. A bougie, with deflection pointed posteriorly rather than anteriorly, can be used as an adjunct.

Use intermittent suction—constant suction can lead to gastric mucosal damage

If the NGT has been confirmed to be in the stomach and there is minimal return during lavage, the drainage holes may be clogged, the tube may be a hold of the gastric wall, or the stomach may be empty—consider decreasing the vacuum pressure setting or you can attempt to push air into the venting lumen with a large syringe.

Cognitive

NGT placement might require multiple attempts

There is a higher incidence of insertion into the pulmonary tree in this group. Alternative techniques include using Magill forceps and a gum-elastic bougie.

Larger-sized NGTs may be difficult to pass in narrow nasal passages, whereas smaller-sized tubes may bend too easily and curl in the patient’s mouth (FIGURE 31.1)

If there are any concerns that the patient may bite down, do not place your fingers in the mouth

In patients who are unconscious or have altered mental status, consider airway protection via intubation before NGT insertion to prevent aspiration

In the case of hematemesis, NGT lavage is used to remove blood irritating the stomach, to determine the amount of blood, and to determine whether bleeding persists. It is not performed in order to diagnose a bleed; a negative NGT aspirate does not rule out a clinically important bleed.