Pain management prior to nasogastric tube placement: atomized lidocaine

Nasogastric tube (NGT) insertion is often painful for patients of all ages. Randomized clinical trials in adult patients support the use of some form of topical lidocaine in reducing pain associated with NGT insertion. A review of pediatric evidence also confirms that NGT insertion is painful and provides guidance in determining lidocaine concentrations, dosages, and administration methods. The Iowa Model of Evidence-Based-Practice to Promote Quality Care provided the framework for development of a weight-based standard of practice (SOP) for administration of atomized lidocaine prior to NGT insertion for all patients. To facilitate usage, the orders for NGT placement and atomized lidocaine administration were linked in the electronic health record (EHR). Atomized lidocaine was administered via a patient-specific intranasal mucosal delivery device. Evaluation measures included pre- and post-implementation questionnaires which measured discomfort with NGT insertion in pediatric patients (0-10 scale; pre-implementation mean = 7.4; post-implementation mean = 6.5), monitoring utilization of atomized lidocaine via automated dispensing cabinet reports, soliciting comments from families and users, and monitoring institutional patient safety (incident) and adverse drug reaction reports. No patient safety or adverse drug reactions related to atomized lidocaine were identified post-implementation. Patients of all ages have benefited from administration of weight-based intranasal atomized lidocaine to decrease pain caused by NGT insertion. Ongoing safety evaluation and research is warranted since this is the first known report in the literature describing implementation of a weight-based dosing SOP.