Enteral feeding and drainage tubes

Types of tube

Nasogastric

Enteral tube routinely placed in critical care patients to provide nutrition and oral medication, or to drain/decompress the stomach.

• Never use excessive force during insertion if tube does not pass smoothly. Due to external compression from the endotracheal tube, cuff, McGill forceps, or similar may aid passage through the pharynx in intubated patients (under laryngoscopic guidance).

• Before food, liquid, or drug administration, correct positioning of tip should be verified by two of: aspiration of acidic fluid (pH <5), positive auscultation over gastric area when air is injected, and radiological confirmation. Auscultation is the least specific technique and should not be relied upon alone.

• The tube should be tethered securely to the nose. In agitated patients, this may require a sling or suture, especially if repeatedly removed.

• Tube insertion depth should be recorded and regularly checked to ensure non-migration proximally.

A nasogastric tube is contraindicated if there is:

• Any nasopharyngeal or upper GI pathology that obstructs lumen or increases risk of perforation/bleeding, unless expert advice is first obtained (e.g. ENT, GI specialist).

• Bleeding oesophageal varices (non-bleeding varices are not an absolute contraindication).

• Base of skull fracture.

• Severe coagulopathy.

Orogastric

• Sited if contraindication to nasal route, e.g. basal skull fracture.

• Otherwise, similar rules as above apply to NG tube though it is difficult to securely tether and is less well tolerated by patient.

Nasoduodenal/nasojejunal

• Used for gastric outlet obstruction or prolonged gastric ileus.

• Sited radiologically under endoscopic guidance or blind (a weighted tube migrates distally from the stomach over time).

Percutaneous enterogastrotomy (PEG)/jejunostomy (PEJ)

Feeding tube inserted percutaneously under radiological or endoscopic guidance or by direct surgical placement.

• Mainly used for long-term nutrition in patients who cannot maintain adequate oral intake, such as head and neck pathology (e.g. cancer), swallowing difficulties (e.g. stroke, severe head injury). The risk of aspiration pneumonia is reduced.

• Avoid in patients with severe coughing.

• Correct coagulopathy before insertion (platelets >50x10 9 /L and INR <1.5).

• Usually retained with an intraluminal balloon 9 attachment to skin.

• Follow local guidelines (antibiotic prophylaxis, period of delay before use, initial introduction of water pre-feeding, site care, etc.).

• Such tubes carry a 3–8% morbidity rate and mortality <1% from infection, perforation, internal leakage, peritonitis, bleeding.