Can I insert a Nasogastric Tube (NGT) in this patient?

Can You Insert a Nasogastric Tube (NGT)?

Yes, you can insert an NGT in most clinical situations, but you must first assess for absolute contraindications (mechanical GI obstruction requiring surgery, active peritonitis, uncorrectable coagulopathy, bowel ischemia) and carefully weigh relative contraindications against clinical necessity. 1

Absolute Contraindications - Do NOT Insert NGT

You cannot proceed with NGT insertion if any of these are present:

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

Relative Contraindications - Proceed with Extreme Caution

These conditions require careful risk-benefit assessment before proceeding:

• Recent facial trauma or oronasal surgery - risk of misplacement into cranial vault or worsening injury 1, 2
• Abnormal nasal anatomy - increases difficulty and complication risk 1
• Recent GI bleeding (especially peptic ulcer with visible vessel or esophageal varices) - delay 72 hours if possible 1
• Hemodynamic instability - stabilize first 1
• Severe respiratory compromise - high risk of desaturation during insertion 1, 3

Primary Indications for NGT Insertion

Gastric decompression:

• Patients undergoing rapid sequence intubation with high aspiration risk 1
• Gastric distention (assess with point-of-care ultrasound; consider if gastric fluid volume >1.5 mL/kg) 1, 3
• Postoperative decompression in select cases (though routine use after pancreatoduodenectomy is not recommended) 4, 5

Enteral nutrition:

• Patients unable to meet nutritional requirements orally for 5-7 days (or 24-48 hours if severely malnourished) 1
• Dysphagia from stroke, neurologic disease, head/neck cancer 1
• Unconscious or ventilated patients requiring nutritional support 1

Special Patient Populations Requiring Modified Approach

COVID-19 patients:

• Continue enteral nutrition via NGT until discharge seems likely before considering gastrostomy 4
• Wait until patient is afebrile, off pressors, with stable hemodynamics before any invasive procedures 4

Neonates with epidermolysis bullosa:

• Use experienced staff for insertion with well-lubricated tube 4
• Prefer NGT over orogastric tubes (less mucosal trauma) 4
• Secure with low-adherent film contact layer, then tape to film (never tape directly to skin) 4

Trauma patients with duodenal injury:

• Place NGT for proximal decompression after repair 4
• Essential component of management for WSES class I-III duodenal lacerations 4

Critical Safety Considerations

Risk of poor outcomes:

• NGT insertion is associated with increased risk of severe/complicated outcomes in Clostridioides difficile infection (RR 1.81) - avoid unnecessary use 4
• Increased risk of pneumonia and respiratory failure compared to no NGT in small bowel obstruction without active emesis 6

Desaturation risk during insertion:

• Preoxygenate hypoxemic patients (use NIPPV if PaO₂/FiO₂ <150) 3
• Position obese patients with head elevation 25-30° to increase functional residual capacity 3
• Recognize that nasal bleeding, gagging, vomiting, or inadvertent tracheal placement can cause rapid desaturation 3

Insertion technique to minimize complications:

• Use generous lubrication 2
• Consider direct visualization or fluoroscopy in difficult cases 2, 7
• Have experienced staff perform insertion in high-risk patients (epidermolysis bullosa, esophageal fragility) 4

Mandatory Post-Insertion Verification

You must confirm proper placement before any feeding or medication administration:

• Radiographic confirmation is the gold standard 1, 8
• pH testing of aspirate (should be <5.5) can be used for subsequent position checks 1
• Never rely solely on auscultation - this is inadequate and dangerous 1

When NOT to Use NGT Despite Indication

Small bowel obstruction without active emesis:

• Routine NGT decompression increases pneumonia risk, respiratory failure, time to resolution, and hospital length of stay 6
• Reserve for patients with active, persistent vomiting 6

Upper GI bleeding:

• Routine NGT placement does not improve physician ability to predict high-risk lesions 9
• Does not affect rebleeding rates or mortality 9
• Causes complications (pain, nasal bleeding, placement failure) in 34% of patients 9
• Only use if specific therapeutic benefit expected 9

Duration and Transition Planning

• NGT is appropriate for short-term use (<4 weeks) 1
• Consider percutaneous endoscopic gastrostomy (PEG) if enteral access needed >4 weeks 1
• Early PEG may be preferred over prolonged NGT in ventilated stroke patients (lower ventilator-associated pneumonia rates) 1