American Journal of Emergency Medicine (2011) 29, 386–390

www.elsevier.com/locate/ajem

Original Contribution

Lidocaine gel as an anesthetic protocol for nasogastric tube

insertion in the ED
Ofir Uri MD ⁎, Lior Yosefov MD, Amir Haim MD, Eyal Behrbalk MD, Pinchas Halpern MD
Department of Emergency Medicine, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine,
Tel Aviv University, Tel Aviv 64239, Israel

Received 12 September 2009; revised 21 October 2009; accepted 24 October 2009

Abstract
Objective: The aim of the study was to evaluate the efficacy of topical 2% lidocaine gel in reducing pain
and discomfort associated with nasogastric tube insertion (NGTI) and compare lidocaine to ordinary
lubricant gel in the ease in carrying out the procedure.
Methods: This prospective, randomized, double-blind, placebo-controlled, convenience sample trial was
conducted in the emergency department of our tertiary care university-affiliated hospital. Five milliliters
of 2% lidocaine gel or placebo lubricant gel were administered nasally to alert hemodynamically stable
adult patients 5 minutes before undergoing a required NGTI. The main outcome measures were overall
pain, nasal pain, discomfort (eg, choking, gagging, nausea, vomiting), and difficulty in performing the
procedure. Standard comparative statistical analyses were used.
Results: The study cohort included 62 patients (65% males). Thirty-one patients were randomized to
either lidocaine or placebo groups. Patients who received lidocaine reported significantly less intense
overall pain associated with NGTI compared to those who received placebo (37 ± 28 mm vs 51 ± 26
mm on 100-mm visual analog scale; P b .05). The patients receiving lidocaine also had significantly
reduced nasal pain (33 ± 29 mm vs 48 ± 27 mm; P b .05) and significantly reduced sensation of gagging
(25 ± 30 mm vs 39 ± 24 mm; P b .05). However, conducting the procedure was significantly more
difficult in the lidocaine group (2.1 ± 0.9 vs 1.4 ± 0.7 on 5-point Likert scale; P b .05).
Conclusion: Lidocaine gel administered nasally 5 minutes before NGTI significantly reduces pain and
gagging sensations associated with the procedure but is associated with more difficult tube insertion
compared to the use of lubricant gel.
© 2011 Elsevier Inc. All rights reserved.

1. Introduction recognized and investigated. Singer et al [1] found NGTI

to be the single most painful routine ED procedure. A survey
Nasogastric tube insertion (NGTI) has been used among ED physicians conducted recently by Juhl and
routinely in emergency medicine for more than a century Conners [2] found that more than 90% of responders were
and is one of the most commonly performed procedures in aware of the pain and discomfort associated with NGTI and
the emergency department (ED). The pain and discomfort used measures to reduce it, but fewer than 30% of them
associated with the procedure has only recently been believed that the available measures were adequate. Most of
the physicians who participated in the survey were willing to
⁎ Corresponding author. Tel.: +972 52 4262285; fax: +972 3 6974775. change their usual practices based on new evidence on
E-mail address: ofiruri@gmail.com (O. Uri). effective analgesic measures for NGTI.

0735-6757/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajem.2009.10.011
Lidocaine gel anesthesia for nasogastric tube insertion 387

A number of studies evaluated the efficacy of several purpose of this study. After obtaining their written informed
anesthetic regimens (eg, lubricants, topical vasoconstrictors, consent, the enrolled patients were randomized to nasally
and topical anesthetics applied by gel/spray/nebulizer/atom- receive either 5 mL of 2% lidocaine gel or 5 mL of
izer) for the alleviation of pain and discomfort associated with nonanesthetic water-based lubricant gel (K-Y gel, Johnson &
NGTI. Spektor et al [3] instilled topical 0.5% phenylephrine Johnson, New Brunswick, NJ). Randomization was achieved
and 5 mL of 2% lidocaine gel to 10 young healthy volunteers by opening sealed coded envelopes, each containing an
and then administered 3 anesthetic combinations of nebulized identical 5-mL syringe with lidocaine or placebo gel. The
lidocaine, oral lidocaine spray, and placebo spray. They found envelopes were prepared in advance in sets of 10 with equal
that the addition of nebulized lidocaine to topical phenyleph- numbers of lidocaine and placebo assignments and kept in the
rine and lidocaine gel resulted in less pain and discomfort ED refrigerator. Patients, nurses, and physicians involved in
during NGTI. Ducharme and Matheson [4] evaluated the the study remained blinded to the intervention assignments.
effectiveness of 3 topical anesthetics (1.5 mL of 4% atomized All procedures were performed by 1 of 8 registered nurses
lidocaine, 1.5 mL of 4% atomized cocaine, and 5 mL of 2% involved in the study, using the same method. All nurses
lidocaine gel) in 30 healthy volunteers. Their results showed involved in the study were experienced ED nurses, specialty-
that the level of discomfort was lower when 2% lidocaine gel trained, and government-certified in emergency nursing,
was used compared to the other anesthetics. Singer and Konia who had performed more than 100 NGTIs before this study.
[5] prospectively assessed pain reduction in 40 alert adults The patients were positioned in a semiseated position and
requiring NGTI in the ED setting. They found that topical 2% asked to inhale through the nose, so that the more patent
lidocaine gel with 0.5% phenylephrine for the nose and 2% nostril could be identified. Five milliliters of lidocaine or
tetracaine with 14% benzocaine spray for the throat resulted in placebo gel were instilled to the more patent nostril, and the
significantly less pain and discomfort than a nasal lubricant patients were instructed to inhale the gel and to swallow it
gel alone. when it reached the pharynx. A 16F NGT was inserted 5
Some of the anesthetic protocols suggested in these and minutes after gel application in both groups to enable the
other studies may be too complicated for routine use in the anesthetic effect of lidocaine on the mucous membrane of the
ED and include medications that are not always available in nose and pharynx to reach its peak [7]. The tip of the tube
the ED. The objective of this study was to evaluate the was lubricated with a small amount of placebo gel before
effectiveness of a simple and readily available anesthetic insertion for additional lubrication. The tube was gently
protocol, nasally instilled 5 mg of 2% lidocaine gel, advanced parallel to the nasal floor until reaching the
compared to placebo, for the alleviation of pain and nasopharynx. At this point, the patient was asked to sip 50
discomfort associated with NGTI. mL of water given by a syringe to induce swallowing and
assist tube progression. In case of resistance or difficulty, the
tube was withdrawn and insertion was reattempted. The
2. Materials and methods NGT placement was confirmed by auscultation and
aspiration of gastric contents.
2.1. Study setting and sign

This prospective randomized double-blind placebo-con-

2.3. Outcome measures
trolled study was approved by the institutional ethics
committee. It was conducted in the adult ED of our tertiary Immediately after insertion and securing the NGT, the
care university-affiliated hospital. The ED has approximately patient were asked to rate their pain levels and the selected
160 000 adult patient visits per year. The study patients were discomfort measures (eg, overall pain, nasal pain, choking,
enrolled from October 2007 to March 2008 on a convenience gagging, nausea) on a 100-mm visual analog scale (VAS).
sample based on the authors' availability. Inclusion criteria The registered nurse performing the procedure rated the
were (1) patients requiring NGTI as decided by the treating difficulty in carrying it out by using a 5-point Likert scale
physician according to the common indications for NGTI (eg, minimal, less difficult than usual, usual amount of
[6], (2) age older than 18 years, (3) willingness and mental difficulty, more difficult than usual, extremely difficult) and
ability to provide informed consent and to complete the study noted the number of attempts and the incidence of
questionnaire, and (4) stable hemodynamic status. Pregnant discomfort. The patients' demographic and clinical data
women and patients receiving anticoagulation therapy and were obtained directly from the medical records.
those with lidocaine hypersensitivity or who sustained acute
trauma were excluded from the study. 2.4. Statistical analysis

2.2. Study protocol Continuous parameters were summarized by means and

SD with 95% confidence intervals (CIs). Proportions with
Patients requiring NGTI in the ED were informed about 95% CI are presented for categorical parameters. A
the medical indication and importance of NGTI and about the comparison between the groups with regard to age and
388 O. Uri et al.

outcome measures was performed using the Mann-Whitney Table 2 Outcome measures
nonparametric test. Categorical parameters, such as sex, Study Control Difference P
indications for NGTI, and vomiting rate, were compared group group (95%CI)
between groups using the χ2 or Fisher exact tests. Multiple n = 31 n = 31
linear regression models were applied to evaluate the effect
Overall pain 37 ± 28 51 ± 26 14 (11 to 17) b.05
of demographic and clinical parameters on overall pain
and discomfort a
score. The statistical analysis was performed using the SPSS Nasal pain a 33 ± 29 48 ± 27 15 (12 to 18) b.05
software for Windows, version 14.0 (SPSS Inc, Chicago, IL). Choking 27 ± 26 42 ± 32 15 (12 to 17) NS
sensation a
Gagging 25 ± 30 39 ± 24 14 (11 to 17) b.05
sensation a
3. Results Nausea a 25 ± 29 40 ± 38 15 (12 to 18) NS
Vomiting 3 (9.7) 3 (9.7) 0 (−16% to 16%) NS
Sixty-two patients were enrolled for this study between (n [%])
October 2007 and March 2008, of whom 40 (65%) were Difficulty of 2.1 ± 0.9 1.4 ± 0.7 0.7 (0.25 to 1.15) b.05
males. The mean age of the study population (±SD) was 66 ± NGTI b
NGTI attempts 1.4 ± 0.7 1.2 ± 0.6 0.2 (−0.2 to 0.6) NS
19 years. Sixty-one patients (98.4%) were Israeli Jews.
(n) (mean ± SD)
Indications for NGTI included small bowel obstruction and a
diagnosis of gastrointestinal bleeding (eg, hematemesis and Visual analog scale of 100 mm.
b
5-point Likert scale.
melena). Half of the 62 participants were randomized to the
treatment group (5 mL of 2% lidocaine gel) and the other half
to the control group (5 mL of K-Y gel). There were no to patients in the control group (37 ± 28 mm vs 51 ± 26 mm
significant differences between the groups in age, sex, and on 100-mm VAS, respectively, difference, 14 mm; 95% CI,
indication for NGTI. The mean age of the study group was 11-17 mm; P b .05). Nasal pain was also less intense among
68 ± 19 years compared to 64 ± 17 for the control group the patients in the study group (33 ± 29 mm vs 48 ± 27 mm;
(difference, 4 years; 95% CI, 1.8-6.2 years; P = not difference, 15 mm; 95% CI, 12-18 mm; P b .05), as was the
significant [NS]). Sex distribution was 61% males in the sensation of gagging (25 ± 30 mm vs 39 ± 24 mm;
study group and 68% males in the control group (difference, difference, 14 mm; 95% CI, 11-17 mm; P b .05). The
7%; 95% CI, −17% to 28%; P = NS). Small bowel choking sensation, nausea, and vomiting rates were similar
obstruction was the indication for NGTI in 35% of the for both groups. Nasogastric tube insertion was successful in
patients in the study group and 48% in the control group all patients, but the difficulty in performing the procedures as
(difference, 13%; 95% CI, −11% to 35%; P = NS). scored by the registered nurses who carried them out was
Hematemesis was the indication for NGTI in 29% of significantly greater in the study group compared to the
patients in the study group and 16% in the control group control group (2.1 ± 0.9 vs 1.4 ± 0.7 on 5-point Likert scale;
(difference, 13%; 95% CI, −8% to 32%; P = NS), and difference, 0.7; 95% CI, 0.25-1.15; P b .05). The average
melena in 35% for both groups (difference, 0%; 95% CI, number of attempts needed for completing the procedure was
−23% to 23%; P = NS). Demographic and clinical data for also higher in the study group but not significant (1.4 ± 0.7 vs
each group are summarized in Table 1. 1.2 ± 0.6; difference, 0.2; 95% CI, -0.2 to 0.6; P = NS).
Patients in the study group reported experiencing less Outcome measures are summarized in Table 2.
intense overall pain associated with the procedure compared We applied multiple linear regression models to evaluate
the effect of demographic and clinical parameters (eg, sex,
Table 1 Patient characteristics age, prior NGTI, difficulty of the current NGTI) on the
outcome measures. Difficulty in performing the index
Study group Control group P procedure was the only parameter that significantly influ-
(n = 31) (n = 31)
enced the outcomes. Specifically, patients who underwent a
Age (y) 68 ± 19 64 ± 17 NS difficult NGTI (scoring ≥ 4 on the 5-point Likert scale) were
(mean ± SD) likely to have a higher overall pain level compared to patients
Sex (n [%]) who underwent an easy NGTI (difference, 24 mm; 95% CI,
Males 19 (61.3) 21 (67.7) NS
19-26 mm; P b .05). Female sex and having undergone a
Females 12 (38.7) 10 (32.3)
previous NGTI showed a tendency (although not significant)
Indication for NGTI (n [%]) to influence the overall pain score related to NGTI.
Small bowel 11 (35.5) 15 (48.4) NS Specifically, females were likely to have a higher overall
obstruction pain compared to males (difference, 12 mm; 95% CI, 9-14
Hematemesis 9 (29.0) 5 (16.1) mm; P = NS), and patients who had undergone a previous
Melena 11 (35.5) 11 (35.5) NGTI were likely to have a lower overall pain compared to
patients for whom this was their first NGTI (difference,
Lidocaine gel anesthesia for nasogastric tube insertion 389

8 mm; 95% CI, 5-11 mm; P = NS). Patient age did not symptoms commonly experienced during NGTI (eg,
influence the outcome measures. choking, gagging, nausea, and vomiting). We found that
gagging was significantly reduced in the study group,
probably due to the anesthetic effect of lidocaine on the
4. Discussion pharynx and elimination of the gag reflex. This effect of
local anesthesia on the gag reflex is reported to reduce the
Nasogastric tube insertion is one of the most painful rate of successful NGTI in placement and to increase the
procedures performed routinely in the ED. The considerable rate of inadvertent tracheal instead of nasogastric intubation
pain and discomfort associated with the procedure mandates [11,12]. This can explain the greater difficulty in the
the use of anesthetic measures. Several protocols of topical performance of the NGTI procedure that was encountered in
anesthetics have been evaluated for that purpose; however, our current study. Similar to our findings, Singer and Konia
none of them has gained wide acceptance. Although they are [5] found that local anesthesia reduced gagging during
effective, some proposed protocols may be too cumbersome NGTI, although reduced gagging was not associated with
for routine use in the busy environment of the ED [3,5]. increased difficulty in carrying out the procedure. We found
There is still no simple, effective, and acceptable protocol for no between-group differences in the other 3 discomfort
the relief of pain and discomfort associated with NGTI. Our measures that were evaluated.
study results demonstrated that 5 mL of 2% lidocaine gel Our multiple linear regression models revealed that
instilled nasally 5 minutes before NGTI significantly reduced patients who underwent difficult NGTIs were likely to have
the overall pain associated with the procedure. Todd et al [8] more overall pain associated with the procedure. These
reported that pain relief of 13 mm (on a standard 100-mm findings are contrary to those of Singer and Konia [5] who
VAS) was the minimum mean change that should be found no correlation between the procedural difficulty and
considered clinically significant. Thus, our finding of a 14- pain scores. The mean overall pain intensity in our study
mm reduction in overall pain and 15-mm reduction in nasal group was significantly lower compared to the placebo group,
pain associated with NGTI are not only statistically despite the higher rate of NGTI difficulty recorded for the
significant but also clinically meaningful. However, it should former group. This finding emphasizes the clinical benefit of
be pointed out that the study by Todd et al [8] dealt with lidocaine gel in reducing pain associated with NGTI.
traumatic injuries and not ED procedures. Wolfe et al [9] Our study has several limitations. First, the population in
demonstrated a reduction of 27 mm in the overall pain the study was quite homogenous, having been made up of
associated with NGTI, when an NGT was inserted Jewish Israeli patients at one facility, and this serves to limit
immediately after administration of atomized lidocaine to the external validity. Second, we found that the use of
the nasopharynx and oropharynx (lidocaine gel was also lidocaine gel resulted in greater difficulty in carrying out the
used as a lubricant, without waiting for its anesthetic effect) procedure, but we failed to document adverse reactions
compared to placebo (64 mm vs 37 mm; difference, 27 mm). associated with difficult NGTIs (eg, nasal bleeding,
Similarly, Cullen et al [10] showed a reduction of 21 mm in esophageal abrasions, pulmonary aspiration, and others).
the overall pain score when an NGT was inserted The occurrence of such adverse reactions might have
immediately after administration of nebulized lidocaine (K- influenced our conclusions. Third, patient selection for this
Y gel was used as a lubricant) compared to placebo (59 mm study was made on a convenience sample based on the
vs 38 mm; difference, 21 mm). The pain relief reported in authors' availability, which can potentially cause a selection
both these studies was greater than the levels reported by our bias. Finally, multiple registered nurses performed the
patients (51 mm vs 37 mm; difference, 14 mm); however, the procedures in this study. Because placement of a NGT is
level of the overall pain after anesthetics administration in operator related, this fact might have been a confounding
the studies done by Wolfe, Cullen, and that of the authors factor. We did not document which nurse performed each of
was similar (around 37 mm). Atomized and nebulized the procedures and therefore could not analyze the influence
lidocaine deliveries have a very rapid anesthetic onset that of the procedure operator on the outcomes. However, all
enables immediate NGTI—a feature that represents an nurses involved were trained emergency nurses, highly
advantage in the busy ED environment compared to the 4- experienced in performing the procedure (had performed
to 5-minute intervals required for lidocaine gel to produce its N100 NGTIs before the study) and used the same method
anesthetic effect. However, atomization and nebulization should restrict this potentially bias.
require special devices, which are not always available in the In conclusion, this study demonstrates the benefit of
ED, and the required preparation is time consuming as well. lidocaine gel in reducing pain associated with NGTI in the
Ducharme and Matheson [4] reported that the overall ED setting and offers a simple and readily available
discomfort associated with NGTI was lower after adminis- anesthetic protocol for that purpose. It should be born in
tration of lidocaine gel compared to other anesthetic mind that lidocaine gel requires 4 to 5 minutes to achieve its
protocols (eg, atomized lidocaine or cocaine). Because maximal anesthetic effect and that this time interval between
“overall discomfort” can be difficult to define, we measured lidocaine administration and NGTI should be observed;
discomfort in this study by using several specific adverse otherwise, the anesthetic would serve merely as a lubricant
390 O. Uri et al.

with no anesthetic properties. Nasogastric tube insertion was [5] Singer JK, Konia N. Comparison of topical anesthetics and
more difficult after lidocaine administration; however, the vasoconstrictors vs. lubricants prior to nasogastric intubation: a
randomized, controlled trial. Acad Emerg Med 1999;6:184-90.
overall pain intensity and gagging sensation were still [6] Witting MD. “You wanna do what?!” Modern indications for
significantly relieved. nasogastric intubation. J Emerg Med 2007;33:61-4.
[7] Schonemann NK, van der Burght M, Arendt-Nielsen L, et al. Onset
and duration of hypoalgesia of lidocaine spray applied to oral mucosa
—a dose response study. Acta Anaesthesiol Scand 1992;36:733-5.
References [8] Todd KH, Funk KG, Funk JP, et al. Clinical significance of reported
changes in pain severity. Ann Emerg Med 1996;27:485-9.
[1] Singer AJ, Richman PB, Kowalska A, et al. Comparison of patient and [9] Wolfe TR, Fosnocht DE, Linscott MS. Atomized lidocaine as topical
practitioner assessments of pain from commonly performed emergen- anesthesia for nasogastric tube placement: a randomized, double-blind,
cy department procedures. Ann Emerg Med 1999;33:652-8. placebo-controlled trial. Ann Emerg Med 2000;35:421-5.
[2] Juhl GA, Conners GP. Emergency physicians' practices and attitudes [10] Cullen L, Taylor D, Taylor S, et al. Nebulized lidocaine decreases the
regarding procedural anaesthesia for nasogastric tube insertion. Emerg discomfort of nasogastric tube insertion: a randomized, double-blind
Med J 2005;22:243-5. trial. Ann Emerg Med 2004;44:131-7.
[3] Spektor M, Kaplan J, Kelley J, et al. Nebulized or sprayed lidocaine as [11] Graham DR, Hay JG, Clague J, et al. Comparison of three different
anesthesia for nasogastric intubations. Acad Emerg Med 2000;7: methods used to achieve local anesthesia for fiberoptic bronchoscopy.
406-8. Chest 1992;102:704-7.
[4] Ducharme J, Matheson K. What is the best topical anesthetic for [12] Kenny JF, Molloy K, Pollack M, et al. Nebulized lidocaine as an
nasogastric insertion? A comparison of lidocaine gel, lidocaine spray, adjunct to endotracheal intubation in the prehospital setting. Prehosp
and atomized cocaine. J Emerg Nurs 2003;29:427-30. Disaster Med 1996;11:312-3.