What are the interventions for a patient experiencing emesis with a nasogastric (NG) tube in place?

From the Guidelines

The most effective intervention for a patient experiencing emesis with a nasogastric (NG) tube in place is to titrate dopamine receptor antagonist (eg, prochlorperazine, haloperidol, metoclopramide, olanzapine) to maximum benefit and tolerance, as recommended by the most recent guidelines 1. When managing emesis in a patient with an NG tube, it is essential to first assess the tube's placement and patency. Confirm proper positioning by checking for gastric contents and pH. If the tube is properly placed, flush it with 30-50 mL of water to ensure it's not clogged. Some key considerations for managing emesis in this context include:

• Adjusting suction: If the NG tube is on continuous suction, switch to intermittent suction or gravity drainage to reduce irritation.
• Administering antiemetics: Give ondansetron 4-8 mg IV every 8 hours or promethazine 12.5-25 mg IV every 6 hours as needed for nausea and vomiting, in addition to the dopamine receptor antagonist.
• Managing pain: If the patient is experiencing pain, administer appropriate analgesics as this can contribute to nausea.
• Repositioning the patient: Elevate the head of the bed to 30-45 degrees to reduce reflux and aspiration risk.
• Monitoring output: Keep track of the volume and characteristics of drainage from the NG tube.
• Assessing for complications: Check for signs of aspiration pneumonia, dehydration, or electrolyte imbalances. If vomiting persists, consider adding a 5-HT3 antagonist (eg, ondansetron) ± anticholinergic agent (eg, scopolamine) ± antihistamine (eg, meclizine) ± cannabinoid, as suggested by the guidelines 1. It is also crucial to review medications and evaluate if any current medications could be contributing to nausea and vomiting, and consider alternative feeding methods or further diagnostic tests if vomiting continues despite these interventions, as discussed in the context of breakthrough emesis 1.

From the FDA Drug Label

The results of these trials are summarized in Table 10. The populations in Table 10 consisted mainly of females undergoing laparoscopic procedures In a placebo-controlled trial conducted in 468 males undergoing outpatient procedures, a single 4-mg intravenous ondansetron dose prevented postoperative vomiting over a 24-hour period in 79% of males receiving drug compared with 63% of males receiving placebo (P <0. 001). Two other placebo-controlled trials were conducted in 2,792 patients undergoing major abdominal or gynecological surgeries to evaluate a single 4-mg or 8-mg intravenous ondansetron dose for prevention of postoperative nausea and vomiting over a 24-hour period. At the 4-mg dosage, 59% of patients receiving ondansetron versus 45% receiving placebo in the first trial (P <0. 001) and 41% of patients receiving ondansetron versus 30% receiving placebo in the second trial (P = 0. 001) experienced no emetic episodes. No additional benefit was observed in patients who received intravenous ondansetron 8 mg compared with patients who received intravenous ondansetron 4 mg. Patients who experienced an episode of postoperative nausea and/or vomiting were given Ondansetron Injection (4 mg) intravenously over 2 to 5 minutes, and this was significantly more effective than placebo. Repeat Dosing in Adults: In patients who do not achieve adequate control of postoperative nausea and vomiting following a single, prophylactic, preinduction, intravenous dose of ondansetron 4 mg, administration of a second intravenous dose of ondansetron 4 mg postoperatively does not provide additional control of nausea and vomiting

The interventions for a patient experiencing emesis with a nasogastric (NG) tube in place are not directly addressed in the provided drug label. However, for patients experiencing emesis, possible interventions include:

• Administration of ondansetron 4 mg intravenously over 2 to 5 minutes 2
• Repeat dosing of ondansetron 4 mg postoperatively may not provide additional control of nausea and vomiting 2 It is essential to note that the provided drug label does not explicitly address the management of emesis in patients with a nasogastric (NG) tube in place. Therefore, the above interventions may not be directly applicable to this specific scenario.

From the Research

Interventions for Emesis with a Nasogastric (NG) Tube

To manage emesis in a patient with a nasogastric (NG) tube, several interventions can be considered:

• Checking the NG tube placement to ensure it is correctly positioned in the stomach 3, 4
• Using methods such as colorimetric capnography or epigastric auscultation to verify tube placement 4
• Aspirating stomach contents to relieve nausea and vomiting 5
• Administering antiemetic medications to prevent or treat nausea and vomiting, although the use of a NG tube itself may not reduce the incidence of postoperative nausea and vomiting 6
• Ensuring the NG tube is properly secured to prevent dislodgment or misplacement 7

Verification of NG Tube Placement

Verification of NG tube placement is crucial to prevent complications:

• Abdominal radiograph is considered the gold standard for verifying NG tube placement 7
• Other methods such as colorimetric capnography, epigastric auscultation, and visual inspection of aspirates can also be used to verify tube placement 3, 4
• The choice of method may depend on the patient's condition, the availability of equipment, and local preferences 3

Management of Emesis

Management of emesis in a patient with a NG tube requires careful consideration of the underlying cause:

• If the emesis is due to NG tube misplacement, repositioning the tube may be necessary 3, 4
• If the emesis is due to other causes such as postoperative nausea and vomiting, antiemetic medications may be effective 6
• Aspiration of stomach contents and administration of fluids or medications through the NG tube may also be necessary to manage emesis 5