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.