Insertion of a nasogastric tube can...

Insertion of a nasogastric tube can be highly painful for the patient. Small studies have demonstrated that topical anesthesia, including the use of nebulized lidocaine, provides pain relief without significant medicine absorption. The addition of nose breathing while the nebulized anesthetic is delivered by the and of the mouth decreases lung deposition of the nebulized solution.

Cullen and associates compared the use of nebulized lidocaine with nose and inlet breathing or nebulized saline before nasogastric tube insertion to form procedure discomfort. Fifty adults treated in brace emergency departments who required nasogastric tube insertion and did not have pre-existing impairment to gag retroactive or a history of reactive airway disease were randomly pre-treated with nebulized lidocaine (400 mg 4 mL of 10 percent solution)or normal saline (4 mL) in a double-blind manner.

The solution was administered using a face mask and a shut firmlyed gas-powered jet nebulizer with an oxygen f depressed rate of 6 L for minute. The nasogastric tube was inserted immediately after completion of the treatment, using lubricating jelly Patient discomfort was measured with a visual analog scale. The insertion feed indicated the difficulty of the insertion using a Likert scale. Complications were recorded.

The visual analog discomfort scale revealed significantly les pain in the lidocaine arrange than in the placebo assemblage with no difference in perceived insertion difficulty score noted from the nurses. Epistaxis occurred in five of the 29 patients who received lidocaine and in none of the 21 who received normal saline.

The authors decide that the use of nebulized lidocaine effectively contracts discomfort associated with nasogastric tube placement (see accompanying table). An increased likelihood of epistaxis, probably caused by the agency of injury to insensate turbinate and nasal mucosa, is possible wit h topical anesthesia.

RICHARD SADOVSKY, MD

Cullen L et al. Nebulized lidocaine decreases the discomfort of nasogastric tube insertion: a randomized, double-blind trial. Ann Emerg M August 2004:44:131-7

EDITOR 'S NOTE: In an editorial in the same journal, Gallagher 1 reviews the evidence supporting the use of topical anesthesia before nasogastric tube insertion, including (1) lidocaine nasal spray; (2) lidocaine intranasal jelly combined with a tetracaine-plus-benzocaine pharyngeal spray and a nasal vasoconstrictor; (3) nebulized lidocaine added to intransal lidocaine jelly with or without a nasal vaso-constrictor; and (4) the popular report on the efficacy of nebulized lidocaine delivered to the nose and the pharynx. Data indicate that patients should no longer have to sustain nasogastric tube insertion without topical anesthesia. Single-use, disposable atomizers are probably the best way to lessen possible cross-contamination. Nebulizers may have a small advantage throughout atomized spray delivery systems. There has been no evidence of increased inadvertent tracheal intubation secondary to local anesthesia use.--R.S.

Evidence-Based Options for Topical Anesthesia Before Nasogastric Tube Insertion *

Preservative-free lidocaine,10%,4 mL nebulized from face mask (400 mg of lidocaine total) ([dagger])

Preservative-free lidocaine spray, 4% delivered from single-dose atomizer to the nose (15 mL) and pharynx (3 mL) followed at intranasal lidocaine jelly, 2%, 5 mL sniffed and swallowed (280 mg of lidocaine total)

*--Two sprays of phenylephrine, 0.5%,in each nostril may decrease the incidence of nosebleeds.

([dagger])--Do not use in patients with asthma.

REFERENCE

(1) Gallagher EJ Nasogastric tubes: hard to swallow. Ann Emerg M 2004:44:138-41

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