What are the management considerations for a patient with a nasogastric tube (NGT) for drainage?

Nasogastric Tube Drainage Management

Routine prophylactic nasogastric tube placement for drainage should be avoided in postoperative patients, as it provides no benefit and increases complications including pneumonia, atelectasis, and delayed bowel function recovery. 1

When NGT Drainage is Indicated

NGT drainage has limited but specific indications:

• Malignant bowel obstruction when other measures fail to control vomiting and surgical intervention is not appropriate 1
• Severe gastric distension causing respiratory compromise 2
• Infants unable to drink (not in shock) can receive oral rehydration solution via NGT at 15 mL/kg/hour 1

For palliative care patients with bowel obstruction, NGT drainage should only be considered on a limited trial basis after pharmacologic management (octreotide, antiemetics, anticholinergics) has failed. 1

Critical Safety Protocols

Tube Selection and Placement

• Use fine bore tubes (5-8 French gauge) unless repeated gastric aspiration or high viscosity feeds are needed 1, 3
• Verify position with pH testing before every use - auscultation ("whooshing test") is unreliable and no longer recommended 1, 3, 4
• Obtain radiographic confirmation for initial placement, especially in patients with altered reflexes or gastrointestinal disease history 5, 2, 4

Tube Maintenance

• Replace tubes every 4-6 weeks, alternating nostrils to prevent pressure injuries and sinusitis 1, 3
• Flush with 30-60 mL water before and after every medication or feed to prevent blockage 3, 5
• Daily reassessment of continued need is mandatory - remove as early as safely possible 3, 5, 2

Specific Clinical Scenarios

Postoperative Abdominal Surgery

Do not place NGT routinely. Meta-analyses demonstrate no reduction in vomiting or ileus, but significantly increased rates of:

• Pulmonary complications (atelectasis, pneumonia) 1
• Pharyngitis 1
• Delayed return of bowel function 1

Exception: If the stomach was inadvertently inflated during intubation, place an orogastric tube and remove before anesthetic reversal 1

Acute Variceal Bleeding

Avoid NG tube insertion for 3 days after acute variceal bleeding; if absolutely necessary, use only fine bore tubes 1

Pediatric Pneumonia

Avoid NGT in severely ill children as tubes compromise breathing, especially in infants with small nasal passages 1

If NGT feeding is essential, use the smallest tube in the smallest nostril 1

Long-Term Feeding (>4-6 Weeks)

Transition to percutaneous endoscopic gastrostomy (PEG) rather than prolonged NGT use 1, 3

Benefits of PEG over long-term NGT:

• Lower dislodgement rates 3
• Better nutritional outcomes 5
• Improved quality of life 3

Exception: Well-tolerated NGTs may continue beyond 4-6 weeks if the patient refuses PEG or has contraindications 1, 3

Common Pitfalls to Avoid

• Never use auscultation alone to verify tube position - this method has caused fatal bronchial instillations 5, 4
• Never mix crushed medications with enteral formula - increases clogging risk 5
• Never ignore resistance during insertion - may indicate submucosal tunneling or other complications 4
• Never delay removal once drainage is no longer needed - each additional day increases complication risk 3, 5

Aspiration Prevention

• Maintain head of bed elevation at 30-45 degrees during and for 30-60 minutes after medication/feed administration 5
• Recognize that patients with altered gag/swallow reflexes have 9-times higher aspiration risk with NGT 5
• Monitor for emerging clinical signs after insertion: abnormal drainage fluid, hypotension, anemia suggesting complications 4

Discharge Planning

Before discharge with NGT, ensure comprehensive education on:

• Feed type, amount, and administration duration 3
• Pump operation 3
• Proper tube fixation techniques 3
• Personal care and daily life adaptations 3
• Community prescription arrangements for feeds and equipment 1