How to place a nasogastric feeding tube in your veterinary patient | VETgirl Veterinary Continuing Education Videos
In this VETgirl online veterinary continuing education video, we review how to place a nasogastric feeding tube in your veterinary patient. Nasogastric (NG) or nasoesophageal (NE) tubes can be a valuable tool to utilize in your practice. Although feeding tubes may seem intimidating to place, if you follow some simple guidelines, you can successfully and easily place them in general, emergency, or specialty practice.
Nasogastric (NG) or nasoesophageal (NE) tubes are commonly used in critical patients to provide short-term nutritional support, measure gastric residual volumes, help with patient comfort and nausea levels by keeping the stomach empty, and potentially help minimize the risk of regurgitation and secondary aspiration pneumonia. They are often well tolerated and can be simply removed once they are not needed. In VETgirl’s experience, cats tolerate these more than dogs!
To place an NG tube, first ensure that you are well-prepared and have all your supplies ready. This includes an appropriately-sized feeding tube, suture, syringes, a 22 or 20-gauge needle, a laryngoscope, a bowl, a needle driver, proparacaine, an E-collar, sterile lubrication, sedation, eye lubrication, and potentially flow by oxygen and monitoring devices. As you prepare everything, place a few drops of proparacaine into the nostril to allow it time to take effect; tip the nose upward to allow the anesthetic to coat the nasal mucosa.
Light sedation may assist with placement, such as 0.2 mg/kg butorphanol and 0.1-0.5 mg/kg midazolam. Try to maximize your sedation by utilizing this for the actual insertion of the NG tube versus initial preparation.
To ensure appropriate length of placement, measure the feeding tube from the nostril to the 7th or 8th rib for an NE tube or the 13th rib for a NG tube, and mark this point on the feeding tube as a guide, so you know how far in to insert the tube. Prior to insertion, test the “stickiness” of the stylet by removing the stylet from the NG tube, flushing saline through the tube, then replacing the stylet. This allows for easier removal of the stylet once it’s placed. Lubricate the end of the tube with sterile lube. Prepare the patient in sternal recumbency, and using short, rapid intentional movements, insert the tube into the nasal passage towards the ventral meatus, while aiming medially, towards the pre-marked location.
Appropriate placement of the feeding tube should be confirmed by visualization of the tube bypassing the larynx and entering the esophagus on oral examination with a laryngoscope (if the patient is adequately sedated), by the presence of negative pressure on aspiration (or the presence of gastric fluid), and by confirmation of a lateral radiograph. Ideally, the tube should not be sitting against the wall of the stomach, but rather sit in the lumen, to help potentially minimize the risk of occluding the fenestrations of the tube. Once the tube is confirmed to be in an appropriate location, secure the tube with a fingertrap suture pattern, starting with stay sutures through the lateral nares. Another stay suture should be placed to secure the tube near the zygomatic arch. Avoid securing the tube too tightly adhered to the face, as it can lead to skin irritation or pressure sores. Also, try to minimize tube or suture contact with the sensitive whiskers!
As a general guideline, suction the tube at least every 4-6 hours to evaluate the patient’s gastric motility and emptying. Once the patient is stable, is no longer vomiting or nauseated, and has normal physiological parameters (e.g., temperature, blood pressure, perfusion, gut sounds, etc.), you can begin with 1/4 RER and gradually increase the rates as tolerated slowly. As a general rule, NG tubes should not be in for longer than a week, as it can lead to nasal irritation and tends not to be well tolerated after that. That said, NG tubes are well tolerated, and are easy to place and remove.
I’ll leave you with a few tips about feeding tubes too!:
Tip: Even if the patient is intubated, you need to verify that the tube is in the esophagus, as an endotracheal tube will not fully occlude the tube from entering the trachea.
Tip: It is a common misconception that patients cannot eat with an NG tube in place. Don’t worry, they can, so continue to offer food and once the patient is eating well, go ahead and remove the tube.
Tip: Oral medications should be avoided through the tube, as it will increase the risk of the tube getting plugged up. If they plug up, try flushing some soda or pop down the line to unclog it!