From the Guidelines
To manage vomiting during nasogastric tube insertion, the most effective approach is to avoid routine nasogastric intubation altogether, as it does not improve outcomes and may increase the risk of complications, as supported by high-quality evidence from studies such as 1 and 1. When nasogastric tube insertion is necessary, proper patient positioning with the head elevated 30-45 degrees to reduce the risk of aspiration is crucial. Consider pre-medicating with an antiemetic such as ondansetron 4-8 mg IV or metoclopramide 10 mg IV 30 minutes before the procedure, as recommended by 1. Using a smaller diameter tube (12-14 French for adults) and adequate lubrication with water-soluble gel can minimize stimulation of the gag reflex. During insertion, have the patient sip water through a straw or perform swallowing movements when the tube reaches the oropharynx to facilitate passage and reduce gagging. If vomiting occurs, immediately stop the procedure, position the patient on their side, and suction as needed to prevent aspiration. Applying topical anesthetics like lidocaine spray (10 mg/spray, 3-5 sprays) to the posterior pharynx or using lidocaine gel on the tube can help reduce the gag reflex. These interventions work by decreasing sensory stimulation in the oropharynx and stomach, while antiemetics block chemoreceptor trigger zones or act on serotonin receptors to prevent the vomiting reflex from activating during this stimulating procedure, as noted in studies such as 1 and 1.
Some key points to consider:
- Avoid routine nasogastric intubation, as it may increase the risk of complications, as supported by 1 and 1
- Use proper patient positioning and pre-medication with antiemetics to reduce the risk of vomiting, as recommended by 1
- Minimize stimulation of the gag reflex by using a smaller diameter tube and adequate lubrication, as suggested by 1 and 1
- Be prepared to stop the procedure and suction as needed if vomiting occurs, to prevent aspiration, as noted in 1 and 1
From the Research
Management of Vomiting during Nasogastric Tube Insertion
To manage vomiting during nasogastric tube insertion, several strategies can be employed:
- Pre-emptive use of metoclopramide infusion to alleviate nausea and discomfort associated with nasogastric tube insertion, as demonstrated in a randomised, double-blind, placebo-controlled trial 2
- Administration of metoclopramide to prevent pneumonia in patients with stroke fed via nasogastric tubes, which may also help reduce vomiting and gastro-oesophageal regurgitation 3
- Selection of the most appropriate approach for nasogastric tube insertion, considering patient condition and clinical factors, as well as the practitioners' sufficient education and experience 4
- Verification of the correct position of the nasogastric tube through radiography, pH testing, end-expiratory carbon dioxide monitoring, or ultrasonography to reduce the incidence of complications, including vomiting 5
Prevention of Gastric Regurgitation
Prevention of gastric regurgitation during endotracheal intubation can be achieved through:
- Use of metoclopramide to increase lower esophageal sphincter tone and prevent gastroesophageal reflux, although its efficacy in preventing gastric regurgitation during endotracheal intubation is still being studied 6
- Avoidance of cricoid pressure, which can hinder intubation and cause lower esophageal sphincter relaxation 6
Key Considerations
Key considerations for managing vomiting during nasogastric tube insertion include:
- Patient condition and clinical factors, such as history of gastrointestinal diseases 5
- Practitioners' sufficient education and experience in nasogastric tube insertion 4
- Emerging clinical manifestations following nasogastric tube insertion, such as abnormal nature of the gastrointestinal decompression drainage fluid, hypotension, and anaemia 5