NASOGASTRIC TUBE INSERTION

FOR PEDIATRIC PATIENTS

Dr. Michael Jude D. Medalla, M.D

Background
Gastric intubation via the nasal passage (ie,
nasogastric route) is a common procedure
that provides access to the stomach for
diagnostic and therapeutic purposes. A
nasogastric (NG) tube is used for the
procedure. The placement of an NG tube can
be uncomfortable for the patient if the
patient is not adequately prepared with
anesthesia to the nasal passages and specific
instructions on how to cooperate with the
operator during the procedure

Indications
Diagnostic indications for NG intubation
include the following:
Evaluation of upper gastrointestinal (GI)
bleeding (ie, presence, volume)
Aspiration of gastric fluid content
Identification of the esophagus and
stomach on a chest radiograph
Administration of radiographic contrast
to the GI tract

Indications
Therapeutic indications for NG intubation include the following:
Gastric decompression, including maintenance of a decompressed
state after endotracheal intubation often via the oropharynx
Relief of symptoms and bowel rest in the setting of small-bowel
obstruction
Aspiration of gastric content from recent ingestion of toxic
material
Administration of medication
Feeding
Bowel irrigation
NG tube can be kept following corrosive ingestion for the
development of atract in the esophagus that subsequently can be
used for balloon dilatation

Contraindications
Absolute contraindications for NG intubation include
the following:
Severe midface trauma
Recent nasal surgery
Relative contraindications for NG intubation include
the following:
Coagulation abnormality
Esophageal varices or stricture
Recent banding of esophageal varices
Alkaline ingestion

Equipment
NG tube (for adult patients) - 16-18 French
NG tube (for pediatric patients) - In pediatric patients, the correct tube
size varies with the patient's age; to find the correct size (in French), add
16 to the patient's age in years and then divide by 2, so that for an 8year-old child, for example, the correct size is 12 French ([8 + 16]/2 = 12)
Viscous lidocaine 2%
Oral analgesic spray (benzocaine spray or other)
Syringe, 10 mL
Glass of water with a straw
Water-based lubricant
Toomey syringe, 60 mL
Tape
Emesis basin or plastic bag
Wall suction, set to low intermittent suction
Suction tubing and container

Equipment

Patient Preparation
Anesthesia
Various methods of topical anesthesia for nasogastric (NG) intubation have
been proven effective in pain relief and improve the likelihood of successful NG
intubation.
The use of viscous lidocaine (ie, the sniff and swallow method) was found to
significantly reduce the pain and gagging sensation associated with NG tube
insertion. Viscous lidocaine is discussed in more detail in the Technique section
below.
Alternative techniques include the following:
Nebulization of lidocaine 1% or 4% through a face mask (4 mg/kg; not to
exceed 200 mg per dose in adults) is an option; the authors recommend that a
preservative-free lidocaine (ie, intravenous lidocaine) be used for nebulization
in order to minimize the risk of allergic reaction
An anesthetic spray that contains benzocaine or a tetracaine/benzocaine/butyl
aminobenzoate combination may be applied to the nasal and oropharyngeal
mucosa; be advised that incidents of methemoglobinemia after a single use of
benzocaine topical sprays have been reported to the US Food and Drug
Administration (FDA)

Patient Preparation
Positioning
The patient should be seated in an
upright position.

Placement of nasogastric tube

Explain the procedure of nasogastric (NG) intubation, as well
as its benefits, risks, complications, and alternatives, to the
patient or the patient's representative.
Examine the patient's nostril for septal deviation. To
determine which nostril is more patent, ask the patient to
occlude each nostril and breathe through the other.
Instill 10 mL of viscous lidocaine 2% (for oral use) down the
more patent nostril with the head tilted backwards (see the
images below), and ask the patient to sniff and swallow to
anesthetize the nasal and oropharyngeal mucosa. In pediatric
patients, do not exceed 4 mg/kg of lidocaine. Wait 5-10
minutes to ensure adequate anesthetic effect.

Placement of nasogastric
tube
Estimate the length of insertion by measuring the
distance from the tip of the nose, around the ear,
and down to just below the left costal margin.
This point can be marked with a piece of tape on
the tube.

Placement of nasogastric
tube
Position the patient sitting upright
with the neck partially flexed. Ask the
patient to hold the cup of water in his
or her hand and put the straw in his
or her mouth. Lubricate the distal tip
of the NG tube

Placement of nasogastric
tube
Gently insert the NG tube along the floor of the
nose, and advance it parallel to the nasal floor
(ie, directly perpendicular to the patient's head,
not angled up into the nose) until it reaches the
back of the nasopharynx, where resistance will
be met (10-20 cm).
At this time, ask the patient to sip on the water
through the straw and start to swallow. Continue
to advance the NG tube until the distance of the
previously estimated length is reached

Placement of nasogastric
tube
Stop advancing the tube and completely withdraw it if,
at any time, the patient experiences respiratory
distress, is unable to speak, has significant nasal
hemorrhage, or if the tube meets significant resistance.
Verify proper placement of the NG tube by auscultating
a rush of air (2-3 cc) over the stomach using the 60 mL
Toomey syringe or by aspirating gastric content. The
authors recommend always obtaining a chest
radiograph in order to verify correct placement,
especially if the NG tube is to be used for medication or
food administration.

Placement of nasogastric
tube
Apply benzoin or another skin
preparation solution to the nose
bridge. Tape the NG tube to the nose
to secure it in place. If clinically
indicated, attach the tube to wall
suction after verification of correct
placement.

Complications
Some degree of patient discomfort is common.
Generous lubrication, the use of topical anesthetic,
and a gentle technique may reduce the patients
level of discomfort. Throat irritation may be
reduced with administration of anesthetic lozenges
(eg, benzocaine lozenges) prior to the procedure.
Epistaxis may be prevented by generously
lubricating the tube tip and using a gentle
technique. Other complications that may occur are
respiratory tree intubation and esophageal
perforation.