What are the indications, contraindications, and complications of Nasogastric Tube (NGT) placement?

Nasogastric Tube (NGT): Indications, Contraindications, and Complications

Nasogastric tubes should be used for short-term enteral access (less than 4 weeks) when oral intake is inadequate but gut function is preserved, for gastric decompression in obstruction, or for medication administration, while percutaneous options are preferred for longer-term needs. 1, 2

Indications

Nutritional Support

• Enteral access for patients who cannot meet caloric requirements over 5-7 days or within 24-48 hours for severely malnourished patients 1
• Impaired nutrient intake due to neurologic diseases (stroke, motor neuron disease, multiple sclerosis, Parkinson's disease) 1
• Support for unconscious or ventilated patients 1, 2
• Nutritional support in patients with head and neck cancer, maxillofacial trauma, or radiation stomatitis 1

Decompression

• Gastric decompression for patients with GI obstruction or fistula 1
• Decompression before rapid sequence intubation in patients at high risk of aspiration 2
• Management of gastric distention in critically ill patients 2, 3

Medication Administration

• Route for medication delivery when oral intake is not possible 3
• Administration of medications in patients with dysphagia 2

Contraindications

Absolute Contraindications

• Mechanical obstruction of the GI tract (unless the procedure is for decompression) 1
• Active peritonitis 1
• Uncorrectable coagulopathy 1
• Bowel ischemia 1

Relative Contraindications

• Abnormal nasal anatomy 1
• Recent facial trauma or oronasal surgery 1
• Recent GI bleeding (especially from peptic ulcer with visible vessel or esophageal varices - delay for 72 hours) 1
• Hemodynamic instability 1
• Severe respiratory compromise 1
• Certain anatomic alterations that make placement difficult 1

Complications

Insertion-Related Complications

• Traumatic insertion causing nasal mucosal bleeding 4
• Malposition into the airway leading to respiratory distress 4, 5
• Aspiration of blood clots during insertion in patients with impaired consciousness 4
• Trauma to nasal passages, pharynx, or esophagus 6

Tube-Related Complications

• Dislodgement (40-80% of NG tubes become dislodged without proper securement) 1, 7
• Tube occlusion requiring replacement 1
• Sinusitis with prolonged use (beyond 3-4 weeks) 1
• Aspiration pneumonia (especially in patients with impaired swallowing) 1, 2

Long-Term Complications

• Risk of pneumonia not eliminated by NG tube placement in patients with dysphagia 1
• Discomfort leading to patient removal of tube 1, 7
• Skin irritation and pressure injuries at fixation sites 7

Proper Placement and Verification

Placement Techniques

• Standard bedside placement with patient's head flexed and sips of water to assist passage 2
• Image-guided placement using fluoroscopy or ultrasound for difficult cases 2
• Endoscopic guidance may be used in complex cases 2

Verification Methods

• Radiographic confirmation is the gold standard before initiating feeding 2, 5
• Aspiration of gastric contents and measurement of gastric pH as alternative methods 2
• Never rely solely on auscultation for confirmation of placement 2

Special Considerations

Duration of Use

• NGT is preferred for short-term use (<4 weeks) 1
• Consider percutaneous options (PEG) for longer-term needs (>4 weeks) 1, 2

Securement Techniques

• Nasal bridles have shown reduced unintentional dislodgement compared to adhesive tape (10% vs 36% dislodgement rate) 1
• Securing the NGT to a fine bore suction catheter looped around the nasal septum can be effective in head and neck cancer patients 7

Nutritional Planning

• Multidisciplinary approach involving dietitians, speech pathologists, and clinical nutrition specialists is recommended 1
• Early NG tube feeding may substantially decrease risk of death compared to delayed feeding in stroke patients 1

Pitfalls to Avoid

• Relying on improper insertion length measurement techniques - the nose-earlobe-xiphoid method often results in tubes that are too short 5
• Failing to confirm proper placement radiographically before initiating feeding 2, 5
• Prolonged use of NGT beyond 3-4 weeks increases risk of complications 1
• Inadequate securement leading to frequent dislodgement and need for reinsertion 2, 7