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
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.