Journal of Neurosurgical Anesthesiology
Vol. 15, No. 1, pp. 55–56
© 2003 Lippincott Williams & Wilkins, Inc., Philadelphia

Case Report

Placing Nasogastric Tubes and Intracranial Pressure
Rainer Dziewas, Peter Sörös, Carsten Konrad, Florian Stögbauer, and Peter Lüdemann
Department of Neurology, University Münster, Münster, Germany

Summary: Recently, a new method for placing nasogastric tubes (NGT) in dysphagic
patients was proposed, which uses the swallowing reflex and was therefore called ‘reflex
placement.‘ The authors describe the use of this method in a patient with a large left sided
striatocapsular hemorrhage, in whom decompressive craniotomy had been performed
previously. Whereas the conventional approach of placing NGT led to a massive increase
of intracranial pressure (ICP) and to a decline in cerebral perfusion pressure (CPP), the
new method allowed a swift placement with only minor changes of ICP and CPP. The
strict avoidance of intermittent peaks of ICP constitutes a basic principle of care in
patients with space occupying brain lesions. We therefore suggest that, despite the
admittedly larger effort, the reflex placement of NGTs should be used in such circumstances. Key Words: Enteral nutrition—Decompressive craniectomy—Intracranial pressure—Reflex placement of nasogastric tubes

report on a patient suggesting another indication for the
reflex placement of NGTs.

We recently proposed a new method for placing nasogastric tubes (NGT) in dysphagic patients (1), which, in
the meantime, was successfully adopted by others (2), and
called this technique the ‘reflex placement.‘ In brief, a thin
catheter is inserted through the nostril with its tip being
placed in the oropharynx. The NGT is placed through the
other nostril in approximately the same position. The
swallowing reflex is induced by bolus injection of 0.5 to
2.0 mL of distilled water through the thin catheter. At the
onset of swallowing, which is identified by observation of
the characteristic upward laryngeal movement, the NGT is
moved forward. As this procedure requires the cooperation of two medical staff persons, we suggested its use
only in patients in whom the conventional method (3),
usually performed by one person alone, failed. We now

CASE REPORT
A 69-year-old man presented with left-sided hemiplegia
and somnolence due to a hypertensive striatocapsular
hemorrhage. Treatment was initially conservative. On day
five, decompressive craniotomy became necessary because of perifocal edema and an increasing midline shift
leading to deterioration of level of consciousness. The
postoperative course was uneventful, with normalization
of the intracranial pressure (ICP) monitored via an epidural pressure sensor. The patient was extubated 3 days later.
By this time he was arouseable by minor stimulation and
his left-sided hemiplegia was unchanged. The decision for
enteral feeding was made. During the conventional placement of a NGT, which was successful on the second attempt, the patient repeatedly coughed and gagged, which
resulted in significant increases of the ICP to 34 or 36
mmHg, respectively. In spite of a concomitant rise of ar-

Address correspondence and reprint requests to Dr. Rainer Dziewas,
Department of Neurology, University Hospital of Münster, AlbertSchweitzer-Strasse 33, 48129 Münster, Germany.
Accepted for publication on July 17, 2002.

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R. DZIEWAS ET AL.

terial blood pressure, the cerebral perfusion pressure
(CPP) declined from approximately 70 mmHg to 50
mmHg (Fig. 1, left template). The patient removed the
NGT 1 hour later; repeat placement became necessary.

Keeping the massive ICP-increase in mind, we now chose
the reflex placement, which was promptly successful and
resulted in a comparably smaller increase of ICP (24
mmHg) and only a minor decline of CPP (Fig. 1, right
template).
DISCUSSION
The strict avoidance of intermittent peaks of ICP constitutes a basic principle of care in patients with space
occupying brain lesions (4). We therefore suggest, that
despite the admittedly larger effort, the reflex placement
of NGTs should be used in such circumstances.
REFERENCES

FIG. 1. Changes of arterial blood pressure, intracranial pressure, and
cerebral perfusion pressure during conventional placement (left) and reflex placement (right) of a nasogastric tube. Time (x-axis) in minutes.

Journal of Neurosurgical Anesthesiology, Vol. 15, No. 1, 2003

1. Dziewas R, Lüdemann P, Konrad C, Stögbauer F. Simple method
for placing nasogastric tubes in patients with dysphagia. Lancet
2001;358:725–726.
2. Inoue K, Takano H, Yamada T, Tsuchida Y, Yoshikawa T. Nasogastric tubes in patients with dysphagia. Lancet 2002;359:81.
3. Dyer I, Ashton WB. How to pass a nasogastric tube. Br J Hosp Med
1991;45:45–46.
4. Marik P, Chen K, Varon J, Fromm R, Sternbach GL. Management
of increased intracranial pressure: a review for clinicians. J Emerg
Med 1999;17:711–719.