Placing a nasogastric tube is a lot like cooking rice: If you rush it, you’ll end up with a huge mess and a miserable experience.

All too often, we hand the patient a cup of water with a straw and try to railroad a lubricated tube through the nares, only to have it spring out of the patient’s mouth like an angry cobra riding a wave of vomit. It is not uncommon for patients who have endured this procedure before to openly weep or simply flatly refuse when told it must be performed again.

For this installment of Tricks of the Trade, we’ll look at a few ways to make the NG placement less uncomfortable and traumatic for everyone.

Patient Anesthesia

The first critical item is proper patient anesthesia. There are a variety of effective techniques used, including lidocaine atomizers and nebulized cardiac lidocaine administered by face mask, but my favorite is 2% viscous lidocaine, because it both lubricates and anesthetizes the nasopharyngeal spaces without numbing the vocal cords and upper airway, keeping the patient’s protective cough mechanism largely intact.

Unless the patient must remain upright, lay him flat and squirt 3 mL of viscous lidocaine into each nostril encourage him to “snort” the lidocaine back and swallow it. To keep it from running back down his face, I usually tape the end of two tongue depressors together with a few wraps of silk tape, creating a pair of wooden “salad tongs” that can then be applied to the patient’s nose to keep the nares closed. (See photo 1.) Family members often take advantage of this moment to make references to Woody Woodpecker, Pinocchio, and the Froot Loops® toucan that they think are absolutely hilarious.

Precautions and Timing

Sometimes more than 3 mL per nostril can be given, but remember that each milliliter of 2% viscous lidocaine contains 20 mg of lidocaine. It is safest to assume that the patient will gradually absorb all of this medication. Assuming an ideal weight of 70 kg and that 5 mg/kg is the maximum safe dose of lidocaine, this allows for 350 mg total, or 17.5 mL of 2% viscous lidocaine to be administered to the average patient, as long as he isn’t getting any from another source. Frankly, I think going anywhere near this amount is excessive.

This is the point where the most common mistake happens: People rush it. You need a full 20 minutes to elapse for the best anesthesia to occur before then, the patient will get minimal benefit.

Curling the Tube

While you wait, prepare a small ice bath and get your hands on an oral airway. (The larger sizes work best.) Many oral airways have a groove along the side, and you’ll find that it’s quite easy to push the end of the NG tube into the groove. (Tape is another option.) (See photos 2 and 3.)
Dunk the entire NG/oral airway assembly into your cup of ice and then add just a little cold water to increase thermal conduction. (See photo 4.)
Take this interval to get the usual NG gear into place: chucks, tape, a Toomey syringe for verification of placement, the requisite cup of water and straw for the patient, and so forth.
Once your patient is ready, get him properly positioned before removing the NG tube from the ice bath.
Once the patient is all set with the cup of water in hand and you are 100% ready to go, quickly remove the tube from the ice bath and disconnect it from the oral airway. Your NG tube will have a nice curve to the very end, which will last about 45 seconds. (See photo 5.)

Navigating That Nasopharynx Advance the tube slowly and gently.

Once your NG tube reaches “terror turn” where it must reflect downward from the back of the soft palate toward the esophagus, stop for a few seconds if you meet any resistance (e.g., curses, sputtering) and let the patient become more comfortable.

Often the combination of patient relaxation and the curve you’ve placed in the tube will permit an easy progression into the hypopharynx and esophagus, at which point the patient should be encouraged to take small sips of water to facilitate passage of the tube.

Secure the tube and verify placement as usual.

First-timers will still complain, but NG tube placement veterans will be grateful because the experience has been so much less horrendous than what they have endured in the past.

Potential Risks

Remember not to “ram home” the tube with this technique because the cold NG tube has a slightly firmer tip and the patient’s esophagus is anesthetized, slightly increasing the chance of perforation with aggressive advancement.

Be gentle.

Uh-Oh

If using this cold technique doesn’t work after one or two tries, you can try the opposite extreme: Place the nasogastric tube in a basin of very warm (but not hot) water for 10 minutes or so.

This will make the tube more pliable, and while you won’t have a nice curve to guide the transition toward the hypopharynx, a softer, more supple tube sometimes makes the turn more easily.

She Who Has Gone Before

In closing, I’d like to extend a special thanks to Dr. Michelle Lin, who wrote this column for years; the editors of ACEP News for allowing me to follow in her footsteps; and the various people I intend to steal ideas from for future installments.

Dr. Fisher is an emergency medicine attending at Westerly (R.I.) Hospital. Have a nifty idea you’d like to see in Tricks of the Trade? E-mail it to him at fisherwhit@gmail.com (he promises to give you credit).