Should I insert a nasogastric tube (NGT)?

Nasogastric Tube Insertion: Indications and Considerations

Nasogastric tube insertion should be performed when the benefits outweigh the risks, particularly in patients at high risk of regurgitation of gastric contents during procedures like rapid sequence intubation (RSI) or in patients requiring enteral nutrition who cannot tolerate oral intake. 1

Indications for Nasogastric Tube Insertion

For Gastric Decompression

• High-risk situations for aspiration:
  • Patients with full stomach or gastric distention 1
  • Patients undergoing rapid sequence intubation (RSI) with risk of regurgitation 1
  • Patients with point-of-care ultrasound showing:
    • Presence of solid gastric contents
    • Estimated total gastric fluid volume >1.5 mL/kg (in right lateral decubitus position)
    • Presence of clear fluids in both supine and lateral positions 1

For Nutritional Support

• Patients requiring short-term enteral nutrition (expected duration <4 weeks) 1
• Patients with dysphagia who cannot maintain adequate oral intake 1
• Stroke patients with unfavorable prognosis where a semi-invasive nutrition approach is appropriate as first step 1
• Patients with uncertain prognosis where PEG insertion may not be immediately appropriate 1

Technical Considerations

Tube Selection and Placement

• Use small diameter tubes (8 French) for feeding in stroke patients to reduce risk of internal pressure sores 1
• Larger diameter tubes should only be used when gastric decompression is necessary 1
• Placement should be performed by trained and experienced medical staff 1
• Verify correct position before administering anything through the tube:
  • X-ray verification (gold standard)
  • Aspiration of gastric content
  • Measurement of gastric pH 1, 2

Complications to Monitor

• Insertion-related complications:

  • Nasal bleeding
  • Gagging and vomiting
  • Esophageal perforation
  • Tracheal placement 1
  • Rare but serious: inadvertent insertion into the brain (especially in patients with skull base fractures) 3
  • Tube kinking or true knot formation 4

• Usage-related complications:

  • Increased risk of aspiration pneumonia 5
  • Pharyngolaryngitis and respiratory infections 1
  • Swallowing difficulties in some patients 1

Special Considerations

Perioperative Setting

• Avoid routine postoperative nasogastric decompression after colorectal surgery as it increases risk of fever, atelectasis, and pneumonia 1
• Remove nasogastric tubes placed during surgery before reversal of anesthesia 1

Enteral Nutrition Administration

• Start tube feeding within 24 hours after surgery if indicated 1
• Begin with low flow rate (10-20 ml/h) and increase carefully due to limited intestinal tolerance 1
• May take 5-7 days to reach target intake 1

Dysphagia Management

• Dysphagia therapy should start early in tube-fed patients 1
• If worsening of dysphagia occurs with nasogastric tube, consider:
  • Tube reinsertion
  • Endoscopic evaluation of pharyngeal tube position (tube may be coiling in pharynx) 1

Alternative Approaches

• For long-term feeding (>4 weeks), consider percutaneous tube placement (e.g., PEG) 1
• For upper GI and pancreatic surgery, consider nasojejunal tube or needle catheter jejunostomy 1
• For patients with chronic conditions, self-insertion of nasogastric tubes may be an option after appropriate therapeutic patient education 6

Conclusion

When deciding whether to insert a nasogastric tube, carefully weigh the benefits against potential complications. For gastric decompression before RSI, insert when the risk of regurgitation is high. For nutritional support, consider the expected duration of need and patient prognosis. Always verify tube position before use and monitor for complications.