Nasogastric Tube

Aka: Nasogastric Tube, Gastric Catheterization, NG tube, Nasogastric Feeding Tube

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II. Indications

  1. Reduces Stomach distention
  2. Reduces risk of aspiration (but does not eliminate aspiration risk)
  3. Prolonged Positive Pressure Ventilation

III. Precautions

  1. Nasogastric Tube placement can induce Nausea and Vomiting
    1. Functional equipment (e.g. yanker suction) for immediate suctioning should be available on NG placement
  2. Thick or semisolid gastric contents will not be suctioned by a Nasogastric Tube (with risk of Emesis)

IV. Contraindications

  1. Cribriform plate Fracture (use Orogastric Tube instead)
  2. Maxillofacial Trauma

V. Preparation: Tube Size

  1. Size
    1. Child: 10-14 French
    2. Adult: 14-18 French
  2. NEX Method of estimating length
    1. Bridge of nose to earlobe to xyphoid process
    2. Note centimeter mark at this point of tube
  3. Scalzo method of estimating length
    1. Nasal Insertion Length: (0.25 x height in cm) + 13

VI. Preparation: Pre-medication

  1. Topical Decongestant (decreases Epistaxis risk)
    1. Oxymetazoline (Afrin) 0.05% nasal spray or
    2. Phenylephrine (Neo-Synephrine) 0.5% nasal spray
  2. Topical Anesthesia options
    1. Lidocaine nasal spray 4% by atomizer
    2. Preservative-free Lidocaine 10% by nebulizer
      1. Lidocaine 10% 4 ml (400 mg total)
      2. Nebulize by Face Mask
      3. Do not use if Asthma history
    3. Combination 1: Lidocaine jelly, Cetacaine Spray
      1. Lidocaine 2% intranasal jelly
      2. Tetracaine-Benzocaine (Cetacaine) pharyngeal spray
    4. Combination 2: Lidocaine atomizer and jelly
      1. Preservative-free Lidocaine 4% by atomizer
        1. Spray 4% once in nostril (1.5 ml)
        2. Spray 4% twice at posterior pharynx (3 ml)
      2. Lidocaine 2% Jelly
        1. Sniff 5 ml Lidocaine into nostril and swallow
    5. References
      1. Gallagher (2004) Ann Emerg Med 44:138-41 [PubMed]
  3. Anxiolysis
    1. Midazolam 2 mg IV before procedure
      1. Significantly reduces pain with the procedure and eases placement
      2. Although 1 mg was also trialed in age over 60 years old, it was not effective
      3. Manning (2016) Acad Emerg Med 23(7):766-71 +PMID:26990304 [PubMed]

VII. Protocol: Discontinuing in Resolving Ileus (Adults)

  1. Instill Milk of Magnesia 3 ounces via NG tube
  2. Clamp Nasogastric Tube for 8 hours
  3. Unclamp tube and aspirate residual Stomach contents
    1. Discontinue NG tube if Residual Volume <120 cc
    2. Stomach normally secretes several liters in a day
    3. Small Residual Volume suggests adeguate drainage

VIII. Causes: Blood in gastric aspirate

  1. Upper gastrointestinal Hemorrhage
  2. Oropharyngeal blood (swallowed)
  3. Traumatic insertion
  4. Upper Gastrointestinal Tract injury (from insertion)

IX. Complications: Nasogastric or nasoduodenal Feeding Tubes

  1. General
    1. Self-Extubation (common)
    2. Increased secretions and need for suctioning
    3. Increased need for repositioning
    4. Clogged or kinked Feeding Tube
    5. Secondary mechanical obstruction from Feeding Tube (pylorus obstruction or Small Bowel Obstruction)
  2. Nasopharyngeal Trauma
    1. Epistaxis
    2. Otitis Media
    3. Sinusitis
    4. Nasopharyngeal erosions
  3. Trachea, Bronchi and lung
    1. Post-cricoid perichondritis
    2. Misdirected tube into airway (with risk of infusion directly into lung)
    3. Tracheoesophageal fistula
    4. Pneumothorax
    5. Gastric aspiration with secondary pneumonitis
    6. Lung Abscess
    7. Tracheobronchial perforation
    8. Airway obstruction
  4. Esophagus
    1. Esophageal bleeding
    2. Esophageal or duodenal perforation
    3. Esophageal Stricture
    4. Esophagitis or Esophageal reflux
    5. Rupture of Esophageal Varices

X. References

  1. Finucane (1999) JAMA 282:1368 [PubMed]
  2. Li (2002) Am Fam Physician 65(8):1605-10 [PubMed]

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