Nasogastric tube placement

Indications

• Aspiration of stomach contents (poor sensitivity and specificity for diagnosing upper GI bleed)
• Vomiting likely to be dangerous or recurrent
  • Bowel obstruction
  • Paralytic ileus
  • Acute gastric dilatation
• Stomach decompression prior to surgery or peritoneal lavage

Contraindications

• Facial fracture involving cribriform plate

Relative Contraindications

• Severe Coagulopathy
• Gastric bypass and lap band procedures
• Esophageal strictures
• History of alkali ingestion

Equipment Needed

• PPE including gown for practitioner and patient
• NG Tube- typically a 16F or 18F Sump
• Syringe/Bulb- 50-60cc
• Tape
• Emesis basin
• Towels
• Cup of water with straw

Procedure

1. Consent by informing patient of risk, benefits, and alternatives
2. Position patient upright
3. Place towel over patient's gown and emesis basin in lap
4. Estimate length of insertion
   • A standard of 56cm is reasonable)
   • Alternatively measure from tip of nose to earlobe to xyphoid and then add 15cm
5. Check nares for obstruction and pass through the most widely patent nare
6. Provide relief from discomfort
   • Topical vasoconstrictors to both nares
     • Oxymetazoline or phenylephrine
   • Topical Anesthetics (5 min prior to procedure)
     • Benzocaine, tetracaine, nebulized lidocaine (4 or 10%), lidocaine jelly
     • Anesthetize OP, as well, to prevent gagging
   • Antiemetics
     • Zofran and reglan 15 min prior may reduce gagging and nausea
7. Insert tube along floor of nose under inferior turbinate
8. Pause when NGT is in OP
9. Flex neck to decrease chance of tracheal passage
10. Advance into esophagus
    • Sipping water may aid in esphageal passage
    • Withdraw to OP promptly if excessive coughing, gagging, choking or voice change
11. Once NGT is in esophagus, rapidly insert rest of tube to premeasured length
12. Confirm placement
    • Insufflate air while listening over stomach
      • One study shows this discovers only 6% of malplacement
      • Should not be primary confirmation technique
    • Obtain Abd xray
    • Check pH of aspirate
      • pH<5.5 in 99% of cases and has sen of 0.78 and spec of 0.86 at or below this level
13. Secure to patients nose with tape
14. Attach to desired suction, not to exceed 120 mmHg

Complications

• Pulmonary placement
• Intracranial placement
• Increased cervical and cranial pressures with gagging/vomiting
• Epistaxis
• Invagination of stomach lumen into eyes of ngt

See Also

• Upper gastrointestinal bleeding
• Small bowel obstruction