Nasogastric Tube: Minicase

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

Minicase

A 60 year-old man with a history of lower left abdominal pain since 2 days ago. Can not fart and defecating since 3 days ago. In addition, patients felt nausea and vomiting, stomach feels bloated. The abdominal examination shows abdominal distension, increased peristaltic, hyperthympani around the abdominal field, and tenderness in the lower left quadrant. On plain abdominal radiographs, ileus appears as copious gas dilatation of the small intestine and colon.
Working Diagnosis : Ileus Obstructive
Therapy

·        Fasting

·        RL infusion 20 TPM

·        Put NGT

·        Replace DC (fluid balance)

·        Cefotaxime inj 2x1 gr
Nasogastric Tube Assembling Technique (NGT)  

Equipment

The following equipment is needed (also see image below):

• Nasogastric tube
• Adult - 16-18F
• 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
• Generous lubrication, the use of topical anesthetic, and a gentle technique may reduce the patient’s level of discomfort.
• 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

References

Fasikhatun. Ileus Obstructive. http://www.fkumyecase.net Updated Thu 15 of Apr, 2010.
Gil Z Shlamovitz, MD, and Nirav R Shah, MD, MPH. Nasogastric Tube: Treatment & Medication. http://emedicine.medscape.com Updated: May 19, 2010

Sandeep Mukherjee, MB, BCh, MPH, FRCPC. Ileus: Differential Diagnoses & Workup.http://emedicine.medscape.com Updated: Dec 28, 2009