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Chapter 119. Placement of Nasogastric Tube

Ruma Rajbhandari, MD, MPH; Stephen C. Wright, MD

  1. What are the indications for nasogastric tube (NGT) placement?

  2. What are the contraindications to NGT insertion?

  3. What are the immediate and long-term complications associated with NGT insertion?

  4. What is the best method for insertion of an NGT to minimize complications?

  5. What are the standards of care for postinsertion confirmation of position of an NGT?

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Case 119-1

A 69-year-old woman with a past medical history of diabetes mellitus type II, hypertension, and colon cancer, status post remote partial colectomy, developed abdominal pain, nausea, and bilious vomiting for the past twelve hours. Her vital signs were within normal limits with the exception of a heart rate of 110 beats per minute (bpm). She appeared uncomfortable, and her abdominal examination was notable for decreased bowel sounds with a succussion splash, mild guarding, and tenderness to palpation of the left and right lower quadrants without rebound. A CT scan of the abdomen reported a small bowel obstruction with a transition point in the distal ileum.

A nasogastric tube (NGT) was inserted through her nose with appropriate analgesia—auscultation of bubbling sounds in the epigastrium suggested correct placement in the stomach which was confirmed by chest x-ray. The NGT, which suctioned approximately 500 cc of yellowish-green bilious material, was subsequently attached to wall suction. Due to minimal drainage and resolution of her pain over the ensuing 3 days, her inpatient physicians removed the tube from her stomach and successfully advanced her diet.

Nasogastric tube (NGT) insertion is a relatively common procedure performed in the hospital setting for a wide variety of indications, including enteral feeding, administration of drugs and other agents and gastric decompression after trauma or intestinal obstruction. The first use of a nasogastric tube is attributed to a 16th-century Italian professor of anatomy and surgery, Hieronymus Fabircius ab Aquapendent who used a silver tube for enteral feeding. Usually inserted at bedside, NGT placement enables early commencement of enteral feeding, thereby maintaining intestinal function even in critically ill patients. Traditionally, the nasogastric tube is a large tube that is inserted blindly through the patient's nose until its tip lies approximately 10 cm below the gastroesophageal junction. For patients in whom feeding beyond the ampulla of Vater is preferable (eg, pancreatitis, gastroparesis), small-bore postpyloric feeding tubes are also available. Recent advances in endoscopic and feeding tube technology allow postpyloric tube placement, with simultaneous gastric decompression, via double-lumen nasogastric decompression and jejunal feeding tubes. These are placed using flexible transnasal endoscopes that can pass small-diameter (5–6 mm) feeding tubes over a guidewire.

Nasogastric tubes have been used for decades in chronically ill patients to provide bolus enteral feeds on a temporary basis until a more permanent surgical gastrostomy can be carried out. In the 1960s, the invention of total parenteral nutrition (TPN) allowed another method of providing nutrition to critically ill patients. However, a growing body of literature supports the view that patient outcomes are better ...

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