What are the recommendations for nasogastric tube (NGT) insertion in a fasting patient at risk of aspiration?

From the Guidelines

Nasogastric tube (NGT) insertion in a fasting patient at risk of aspiration should be performed with caution, and the decision to insert an NGT should be made on a case-by-case basis, considering the potential benefits and risks, as advised by the Society of Critical Care Medicine 1. When inserting an NGT in a fasting patient at risk of aspiration, it is essential to follow proper techniques to minimize the risk of complications.

• The patient should be positioned with the head elevated 30-45 degrees (semi-Fowler's position) to minimize reflux risk.
• Prior to insertion, apply water-soluble lubricant to the tube and consider using 2% lidocaine gel for nasal comfort.
• The NGT should be measured from the tip of the nose to the earlobe and then to the xiphoid process to determine appropriate insertion length.
• During insertion, ask the conscious patient to swallow small sips of water to facilitate passage of the tube.
• Confirmation of correct placement is essential and should include multiple methods: auscultation over the epigastrium while injecting air, pH testing of aspirate (pH <5 indicates gastric placement), and radiographic confirmation, which remains the gold standard. The use of NGT decompression before intubation may be beneficial in patients at high risk of regurgitation of gastric contents, as it may decrease the intragastric pressure and gastric content volume, thereby lowering the likelihood and severity of emesis and pulmonary aspiration 1. However, the decision to insert an NGT should be made cautiously, considering the potential risks, such as nasal bleeding, gagging, and vomiting, esophageal perforation, and tracheal placement 1. In patients with a full stomach or gastric distention, a clinical assessment, in addition to point-of-care ultrasound, can help determine the need for and effectiveness of NGT 1. The literature suggests an increased risk of regurgitation when point-of-care ultrasound demonstrates the presence of solid gastric contents, an estimated total gastric fluid volume greater than 1.5 mL/kg, or the presence of clear fluids 1. It is crucial to weigh the potential benefits of NGT insertion against the potential risks and to consider alternative methods, such as oral intake or other forms of nutrition, when possible. The American Heart Association/American Stroke Association guidelines also emphasize the importance of assessing the patient's ability to swallow and providing nutrition and hydration to sustain recovery, while minimizing the risk of aspiration pneumonia 1.

From the Research

Recommendations for NGT Insertion in Fasting Patients

• The insertion of a nasogastric tube (NGT) in a fasting patient at risk of aspiration requires careful consideration of the patient's condition and the potential risks and benefits of the procedure 2.
• The use of metoclopramide has been shown to reduce the risk of aspiration and pneumonia in patients with stroke fed via nasogastric tubes 3.
• However, the effectiveness of metoclopramide in preventing gastric regurgitation during endotracheal intubation is unclear, with one study finding no significant difference in the rate of gastric regurgitation between patients receiving metoclopramide and those receiving a placebo 4.
• The use of lidocaine gel as an anesthetic protocol for NGT insertion has been shown to reduce pain and discomfort associated with the procedure, but may make the insertion more difficult 5.
• Pre-emptive metoclopramide infusion has been shown to alleviate pain, discomfort, and nausea associated with NGT insertion 6.

Key Considerations

• The patient's age, National Institute of Health Stroke Score (NIHSS), and history of post-stroke pneumonia should be taken into account when deciding on the insertion of an NGT 2.
• The use of metoclopramide may be beneficial in reducing the risk of aspiration and pneumonia, but its effectiveness in preventing gastric regurgitation during endotracheal intubation is unclear 4, 3.
• The insertion of an NGT should be performed with caution, and the patient should be closely monitored for signs of aspiration or other complications 2.