Nasogastric Tube: Indications, Contraindications, Mini Case, Procedures, and Complication

Gastric intubation via the nasal passage (ie, nasogastric route) is a common procedure that provides access to the
stomach for diagnostic and therapeutic purposes. A nasogastric (NG) tube is used for the procedure. The placement of
an NG tube can be uncomfortable for the patient if the patient is not adequately prepared with anesthesia to the nasal
passages and specific instructions on how to cooperate with the operator during the procedure.
Indications
Diagnostic
• Evaluation of upper gastrointestinal (GI) bleed (ie, presence, volume)
• Aspiration of gastric fluid content
• Identification of the esophagus and stomach on a chest radiograph
• Administration of radiographic contrast to the GI tract
Therapeutic
• Gastric decompression, including maintenance of a decompressed state after endotracheal intubation, often
via the oropharynx
• Relief of symptoms and bowel rest in the setting of small-bowel obstruction
• Aspiration of gastric content from recent ingestion of toxic material
• Administration of medication
• Feeding
• Bowel irrigation
Contraindications
Absolute contraindications
• Severe midface trauma
• Recent nasal surgery
Relative contraindications
• Coagulation abnormality
• Esophageal varices or stricture
• Recent banding or cautery of esophageal varices
• Alkaline ingestion
Nasogastric Tube Assembling Technique (NGT)
Equipment
The following equipment is needed (also see image below):
• Nasogastric tube
o Adult - 16-18F
o Pediatric - In pediatric patients, the correct tube size varies with the patient's age. To find the correct
size, add 16 to the patient's age in years and then divide by 2 (eg, [8 y + 16]/2 = 12F)
• Viscous lidocaine 2%
• Oral analgesic spray (Benzocaine spray or other)
• Syringe, 10 mL
• Glass of water with a straw
• Water-based lubricant
• Toomey syringe, 60 mL
• Tape
• Emesis basin or plastic bag
• Wall suction, set to low intermittent suction
• Suction tubing and container
Positioning
• Position the patient seated upright.
Technique
1. Explain the procedure, benefits, risks, complications, and alternatives to the patient or the patient's
representative.
2. Examine the patient's nostril for septal deviation. To determine which nostril is more patent, ask the patient to
occlude each nostril and breathe through the other.
3. Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head tilted backwards
(as shown in the images below), and ask the patient to sniff and swallow to anesthetize the nasal and
oropharyngeal mucosa. In pediatric patients, do not exceed 4 mg/kg of lidocaine. Wait 5-10 minutes to ensure
adequate anesthetic effect.
4. Estimate the length of insertion by measuring the distance from the tip of the nose, around the ear, and down
to just below the left costal margin. This point can be marked with a piece of tape on the tube. When using
the Salem sump nasogastric tube (Kendall, Mansfield, Mass) in adults, the estimated length usually falls
between the second and third preprinted black lines on the tube.
5. Position the patient sitting upright with the neck partially flexed. Ask the patient to hold the cup of water in
his or her hand and put the straw in his or her mouth. Lubricate the distal tip of the nasogastric tube.
6. Gently insert the nasogastric tube along the floor of the nose and advance it parallel to the nasal floor (ie,
directly perpendicular to the patient's head, not angled up into the nose) until it reaches the back of the
nasopharynx, where resistance will be met (10-20 cm). At this time, ask the patient to sip on the water through
the straw and start to swallow. Continue to advance the nasogastric tube until the distance of the previously
estimated length is reached.
7. Stop advancing and completely withdraw the nasogastric tube if, at any time, the patient experiences
respiratory distress, is unable to speak, has significant nasal hemorrhage, or if the tube meets significant
resistance.
8. Verify proper placement of the nasogastric tube by auscultating a rush of air over the stomach using the 60 mL
Toomey syringe or by aspirating gastric content. Always obtaining a chest radiograph is recommended, in order
to verify correct placement, especially if the nasogastric tube is to be used for medication or food
administration.
9. Apply Benzoin or another skin preparation solution to the nose bridge. Tape the nasogastric tube to the nose to
secure it in place as shown. If clinically indicated, attach the nasogastric tube to wall suction after verification
of correct placement.
Complications
• Patient discomfort
o Generous lubrication, the use of topical anesthetic, and a gentle technique may reduce the patient’s
level of discomfort.
o Throat irritation may be reduced with administration of anesthetic lozenges (eg, benzocaine lozenges
[Cepacol]) prior to the procedure.
• Epistaxis may be prevented by generously lubricating the tube tip and using a gentle technique.
• Respiratory tree intubation
• Esophageal perforation